Provider Demographics
NPI:1073013249
Name:CRAFT, KELSEY DIANE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:DIANE
Last Name:CRAFT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19610 HIGHLAND OAKS DR APT 211
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-9630
Mailing Address - Country:US
Mailing Address - Phone:360-747-2622
Mailing Address - Fax:
Practice Address - Street 1:24850 S TAMIAMI TRL STE 4
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-7010
Practice Address - Country:US
Practice Address - Phone:239-319-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9110854363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant