MEDICARE: LETICIA KELLY CERTIFIED NURSES ASS

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	374U00000X	Home Health Aide	CNA109443	FL
2	376K00000X	Nurse's Aide	CNA109443	FL

General Provider Information

NPI Number	:	1366951600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LETICIA KELLY CERTIFIED NURSES ASS

Provider Business Mailing Address
First Line	:	1535 SW HUNNICUT AVE
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-7007
Country	:	US
Telephone Number	:	561-306-9275
Fax Number	:

Provider Business Practice Location Address
First Line	:	1535 SW HUNNICUT AVE
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-7007
Country	:	US
Telephone Number	:	561-306-9275
Fax Number	:

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

Provider Enumeration Date	:	09/28/2017
Last Update Date	:	02/24/2021

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