Provider Demographics
NPI:1225447345
Name:KELLY, BRIDGET
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:KELLY
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 1:5680 OAK LAKE TRL
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7368
Mailing Address - Country:US
Mailing Address - Phone:412-608-2380
Mailing Address - Fax:
Practice Address - Street 1:7009 DR PHILLIPS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5122
Practice Address - Country:US
Practice Address - Phone:407-218-4550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant