MEDICARE: KELLEY WISE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	APRN11004755	FL

General Provider Information

NPI Number	:	1023656600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY WISE

Provider Business Mailing Address
First Line	:	9 PINE CONE DR STE 102
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32137-8683
Country	:	US
Telephone Number	:	386-445-6191
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 PINE CONE DR STE 102
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32137-8683
Country	:	US
Telephone Number	:	386-445-6191
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2019
Last Update Date	:	02/07/2021

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Directions to “ KELLEY WISE ” Practice Location

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