=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255295234
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. KELLY ANN SPRAGUE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2025
-----------------------------------------------------
Last Update Date | 12/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2954 LUCILLE LN
-----------------------------------------------------
City | MIDDLEBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32068-3900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-614-0732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2954 LUCILLE LN
-----------------------------------------------------
City | MIDDLEBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32068-3900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN9540619
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------