Provider Demographics
NPI:1376253328
Name:SEIBERT, KELLEY MARIE
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:MARIE
Last Name:SEIBERT
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 1:6266 LAKE OSPREY DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34240-8425
Mailing Address - Country:US
Mailing Address - Phone:941-867-2560
Mailing Address - Fax:
Practice Address - Street 1:6266 LAKE OSPREY DR
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34240-8425
Practice Address - Country:US
Practice Address - Phone:941-867-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-30
Last Update Date:2022-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021702363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty