MEDICARE: KENYETTA KELLY

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1083545545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENYETTA KELLY

Provider Business Mailing Address
First Line	:	595 JEFFERSON DR UNIT 110
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33442-9437
Country	:	US
Telephone Number	:	954-218-3598
Fax Number	:

Provider Business Practice Location Address
First Line	:	595 JEFFERSON DR UNIT 110
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33442-9437
Country	:	US
Telephone Number	:	954-218-3598
Fax Number	:

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

Provider Enumeration Date	:	05/26/2026
Last Update Date	:	05/26/2026

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Directions to “ KENYETTA KELLY ” Practice Location

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