MEDICARE: FLORIDA ATLANTIC UNIVERSITY

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363LP2300X	Primary Care Nurse Practitioner
2	207Q00000X	Family Medicine Physician
3	363L00000X	Nurse Practitioner
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
5	261QF0400X	Federally Qualified Health Center (FQHC)

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C11027	OTHER	FL	MEDICARE
6	681903	OTHER	FL	FQHC MEDICARE 2021 FOR BOTH 1650 AND 720 LOCATIONS
7	K3331C	OTHER	FL	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	C7MZP	OTHER	FL	LUCET
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	002Z8	OTHER	FL	BCBS
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093026619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA ATLANTIC UNIVERSITY

Provider Business Mailing Address
First Line	:	1650 OSCEOLA DR
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-5038
Country	:	US
Telephone Number	:	561-803-8880
Fax Number	:	877-409-1795

Provider Business Practice Location Address
First Line	:	1650 OSCEOLA DRIVE
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409
Country	:	US
Telephone Number	:	561-803-8880
Fax Number	:	877-409-1795

Authorized Official
Title or Position	:	CEO
Name	:	LOUISA PONTIROLI KELLY
Credential	:
Telephone Number	:	561-803-8880

Provider Enumeration Date	:	06/29/2010
Last Update Date	:	12/15/2025

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Directions to “FLORIDA ATLANTIC UNIVERSITY ” Practice Location

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