Provider Demographics
NPI:1427567411
Name:DEMELLO, KEVIN (APRN)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:DEMELLO
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 947407
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-7407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:200 HEALTHCARE WAY STE 202
Practice Address - Street 2:
Practice Address - City:NORTH VENICE
Practice Address - State:FL
Practice Address - Zip Code:34275-3669
Practice Address - Country:US
Practice Address - Phone:941-261-0160
Practice Address - Fax:941-261-0165
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN02217363LA2200X, 363L00000X
FLAPRN9406634363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner