MEDICARE: SUSAN 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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	PS26969	FL

General Provider Information

NPI Number	:	1992080493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN KELLY

Provider Business Mailing Address
First Line	:	6975 CONGRESS AVENUE
Second Line	:
City	:	LANTANA
State	:	FL
Zip	:	33462
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6975 CONGRESS AVE
Second Line	:
City	:	LANTANA
State	:	FL
Zip	:	33462-3799
Country	:	US
Telephone Number	:	561-964-9167
Fax Number	:	561-964-3975

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

Provider Enumeration Date	:	10/15/2011
Last Update Date	:	10/15/2011

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Directions to “ SUSAN KELLY ” Practice Location

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