Provider Demographics
NPI:1003250234
Name:CROSS, KELLEY VERONICA (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:VERONICA
Last Name:CROSS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N MAITLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4723
Mailing Address - Country:US
Mailing Address - Phone:407-647-5996
Mailing Address - Fax:407-644-5967
Practice Address - Street 1:301 N MAITLAND AVE
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4723
Practice Address - Country:US
Practice Address - Phone:407-647-5996
Practice Address - Fax:407-644-5967
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9356035363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279688100Medicaid
FL99931Medicare UPIN