MEDICARE: MRS. KELLY ANN KOCIUBA

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	374J00000X	Doula

General Provider Information

NPI Number	:	1386210417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY ANN KOCIUBA

Provider Business Mailing Address
First Line	:	403 NW CANTERBURY CT
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34983-3404
Country	:	US
Telephone Number	:	772-361-8397
Fax Number	:

Provider Business Practice Location Address
First Line	:	403 NW CANTERBURY CT
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34983-3404
Country	:	US
Telephone Number	:	772-361-8397
Fax Number	:

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

Provider Enumeration Date	:	05/30/2021
Last Update Date	:	05/30/2021

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