Provider Demographics
NPI:1073130548
Name:WHITE, KELLIE ANN (MSN, APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:WHITE
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 NE STATE ROAD 47
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:FL
Mailing Address - Zip Code:32693-5035
Mailing Address - Country:US
Mailing Address - Phone:352-538-1327
Mailing Address - Fax:
Practice Address - Street 1:103 US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:FL
Practice Address - Zip Code:32008
Practice Address - Country:US
Practice Address - Phone:386-935-3090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily