Provider Demographics
NPI:1093148611
Name:AHMAD, KELLY KELLER
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:KELLER
Last Name:AHMAD
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 1:8225 LAUREL LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-9791
Mailing Address - Country:US
Mailing Address - Phone:239-200-7131
Mailing Address - Fax:
Practice Address - Street 1:4513 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-9033
Practice Address - Country:US
Practice Address - Phone:239-591-2803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9286678363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily