MEDICARE: KELLY ANNE BOYER

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1508679978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ANNE BOYER

Provider Business Mailing Address
First Line	:	90 ASCEND CIR APT 11309
Second Line	:
City	:	SAINT JOHNS
State	:	FL
Zip	:	32259-4172
Country	:	US
Telephone Number	:	904-728-4672
Fax Number	:

Provider Business Practice Location Address
First Line	:	90 ASCEND CIR APT 11309
Second Line	:
City	:	SAINT JOHNS
State	:	FL
Zip	:	32259-4172
Country	:	US
Telephone Number	:	904-728-4672
Fax Number	:

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

Provider Enumeration Date	:	01/29/2025
Last Update Date	:	01/29/2025

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