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General NPI Number Information
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NPI Number | 1790218634
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Entity Type | Individual
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Provider Name | KELLY KATHLEEN BALLETTI
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Gender | Female
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Dates
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Enumeration Date | 04/07/2017
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Last Update Date | 06/28/2022
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Provider Practice Location Address
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Address Line | 135 SAN LORENZO AVE SUITE #700
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City | CORAL GABLES
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State | FL
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Zip | 33146-1524
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Country | US
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Telephone | 305-444-4979
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Fax |
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Provider Business Mailing Address
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Address Line | 135 SAN LORENZO AVE SUITE #700
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City | CORAL GABLES
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State | FL
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Zip | 33146-1524
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Country | US
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Telephone | 305-444-4979
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 9110317
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License Number State | FL
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