Provider Demographics
NPI:1083967434
Name:KEENER, KELLY KAY
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:KAY
Last Name:KEENER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 3RD ST W
Mailing Address - Street 2:APT 7107
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8809
Mailing Address - Country:US
Mailing Address - Phone:304-677-4512
Mailing Address - Fax:
Practice Address - Street 1:501 6TH ST S
Practice Address - Street 2:DEPT: 6220
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4630
Practice Address - Country:US
Practice Address - Phone:727-767-6492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9350771363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care