Provider Demographics
NPI:1407399470
Name:KELLY, FRED A II (ARNP)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:A
Last Name:KELLY
Suffix:II
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-3652
Mailing Address - Country:US
Mailing Address - Phone:407-952-5705
Mailing Address - Fax:
Practice Address - Street 1:500 WINDERLEY PL #115
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751
Practice Address - Country:US
Practice Address - Phone:407-952-5705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9366837363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily