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General NPI Number Information
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NPI Number | 1033798319
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Entity Type | Individual
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Provider Name | KELLY NAIL
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Gender | Female
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Dates
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Enumeration Date | 04/05/2021
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Last Update Date | 04/05/2021
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Provider Practice Location Address
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Address Line | 608 SW MARVIN BURNETT RD
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City | LAKE CITY
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State | FL
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Zip | 32025-4918
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Country | US
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Telephone | 386-965-5197
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Fax |
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Provider Business Mailing Address
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Address Line | 25220 49TH RD
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City | O BRIEN
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State | FL
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Zip | 32071-4206
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Country | US
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Telephone | 352-538-5230
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | CWCM101389
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License Number State | FL
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