MEDICARE: KELSEY V THERIAULT DO

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
2	207R00000X	Internal Medicine Physician	OS21707	FL

General Provider Information

NPI Number	:	1174265227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY V THERIAULT DO

Provider Business Mailing Address
First Line	:	12225 28TH ST N STE B
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33716-1860
Country	:	US
Telephone Number	:	727-561-4303
Fax Number	:	727-561-9299

Provider Business Practice Location Address
First Line	:	12225 28TH ST N STE B
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33716-1860
Country	:	US
Telephone Number	:	727-561-4303
Fax Number	:	727-561-9299

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

Provider Enumeration Date	:	04/10/2022
Last Update Date	:	08/11/2025

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