Provider Demographics
NPI:1497057608
Name:KELLY, KAREN GAIL (ARNP/CPNP)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:GAIL
Last Name:KELLY
Suffix:
Gender:F
Credentials:ARNP/CPNP
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:KJOSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1717 S ORANGE AVE STE 100
Practice Address - Street 2:NEMOURS CHILDRENS CLINIC, ORLANDO
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2946
Practice Address - Country:US
Practice Address - Phone:407-650-7000
Practice Address - Fax:407-567-5924
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2518382363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006515200Medicaid