Provider Demographics
NPI:1093291361
Name:KELLEY, MEGAN NISSEN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:NISSEN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:NISSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:4730 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2181
Mailing Address - Country:US
Mailing Address - Phone:863-646-5471
Mailing Address - Fax:
Practice Address - Street 1:4730 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2181
Practice Address - Country:US
Practice Address - Phone:863-646-5471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37752183500000X
FLPS60181183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist