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General NPI Number Information
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NPI Number | 1124676580
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Entity Type | Individual
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Provider Name | KELLY JO BLEAKLEY PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/29/2019
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Last Update Date | 06/08/2025
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Provider Practice Location Address
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Address Line | 3450 11TH CT STE 105
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City | VERO BEACH
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State | FL
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Zip | 32960-5012
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Country | US
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Telephone | 772-778-3680
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Fax |
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Provider Business Mailing Address
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Address Line | 141 ROYAL PALM ST
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City | SEBASTIAN
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State | FL
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Zip | 32958-4047
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Country | US
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Telephone | 772-473-3320
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 9269
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 025755
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9117749
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License Number State | FL
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