Provider Demographics
NPI:1477912129
Name:KELLY, AARON BLAKE
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:BLAKE
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4250 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-1917
Mailing Address - Country:US
Mailing Address - Phone:850-526-6700
Mailing Address - Fax:850-526-5021
Practice Address - Street 1:4896A HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-7840
Practice Address - Country:US
Practice Address - Phone:850-526-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9427255363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9427255Medicaid
FLARNP9427255Medicare Oscar/Certification