Provider Demographics
NPI:1194192476
Name:CERUTTI, KELLY MICHELE (ANP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MICHELE
Last Name:CERUTTI
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:MICHELE
Other - Last Name:NORWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:CVS MINUTECLINIC #09300
Mailing Address - Street 2:925 CALIFORNIA AVENUE
Mailing Address - City:WAHIAWA
Mailing Address - State:GA
Mailing Address - Zip Code:96786
Mailing Address - Country:US
Mailing Address - Phone:808-621-7772
Mailing Address - Fax:
Practice Address - Street 1:925 CALIFORNIA AVENUE
Practice Address - Street 2:CVS MINUTECLINIC #09300
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786
Practice Address - Country:US
Practice Address - Phone:808-621-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK104121363LF0000X
AK22569363LF0000X
HI2300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily