MEDICARE: CRYSTAL KELLEY

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1487303665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL KELLEY

Provider Business Mailing Address
First Line	:	3623 FREEMAN RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5549
Country	:	US
Telephone Number	:	904-923-5585
Fax Number	:

Provider Business Practice Location Address
First Line	:	3623 FREEMAN RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5549
Country	:	US
Telephone Number	:	904-923-5585
Fax Number	:

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

Provider Enumeration Date	:	03/23/2022
Last Update Date	:	04/18/2022

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Directions to “ CRYSTAL KELLEY ” Practice Location

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