MEDICARE: MRS. JOSSETTE KELLY

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	163W00000X	Registered Nurse	RN3358862	FL

General Provider Information

NPI Number	:	1952761496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOSSETTE KELLY

Provider Business Mailing Address
First Line	:	4973 CREEKSIDE PARK AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32811-6465
Country	:	US
Telephone Number	:	407-873-5109
Fax Number	:

Provider Business Practice Location Address
First Line	:	4973 CREEKSIDE PARK AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32811-6465
Country	:	US
Telephone Number	:	407-873-5109
Fax Number	:

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

Provider Enumeration Date	:	02/25/2016
Last Update Date	:	02/25/2016

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