=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548807399
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY DENISE KELSEY NURSE PRACTITIONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2019
-----------------------------------------------------
Last Update Date | 01/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2626 GLENWOOD AVE STE 550
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27608-1370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-466-9988
-----------------------------------------------------
Fax | 305-466-9989
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3800 S OCEAN DR STE 209
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33019-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-466-9988
-----------------------------------------------------
Fax | 305-466-9989
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 5012591
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------