Provider Demographics
NPI:1467745935
Name:KELLEY, WILLIAM MICHAEL (RCEP)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:KELLEY
Suffix:
Gender:M
Credentials:RCEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2534 CROWN RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-8461
Mailing Address - Country:US
Mailing Address - Phone:407-644-1820
Mailing Address - Fax:
Practice Address - Street 1:400 CELEBRATION PL
Practice Address - Street 2:400 CELEBRATION PLACE
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-4970
Practice Address - Country:US
Practice Address - Phone:407-644-1820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLK400933611220174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1001551OtherAMERICAN COLLEGE OF SPORTS MEDICINE