Provider Demographics
NPI:1043770803
Name:PAETH, KELLY RENEE (APRN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:PAETH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 LEGACY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7528
Mailing Address - Country:US
Mailing Address - Phone:407-455-0404
Mailing Address - Fax:
Practice Address - Street 1:2441 S HIAWASSEE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6347
Practice Address - Country:US
Practice Address - Phone:407-598-0876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001821363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily