MEDICARE: KELLIE MARY DAVIS

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	163WG0000X	General Practice Registered Nurse	3252282	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3252282	OTHER	FL	REGISTERED NURSE

General Provider Information

NPI Number	:	1528654100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE MARY DAVIS

Provider Business Mailing Address
First Line	:	9254 EMILY CIR
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-3600
Country	:	US
Telephone Number	:	561-309-1631
Fax Number	:

Provider Business Practice Location Address
First Line	:	9254 EMILY CIR
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-3600
Country	:	US
Telephone Number	:	561-309-1631
Fax Number	:

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

Provider Enumeration Date	:	12/17/2020
Last Update Date	:	12/17/2020

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