Provider Demographics
NPI:1497769657
Name:HIGGINS, KELLY (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HIGGINS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1941 MOHICAN TRAIL
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751
Mailing Address - Country:US
Mailing Address - Phone:407-325-6712
Mailing Address - Fax:855-708-2323
Practice Address - Street 1:89 W COPELAND DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2028
Practice Address - Country:US
Practice Address - Phone:407-841-5281
Practice Address - Fax:407-648-9879
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1930852363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305002500Medicaid
FLP00353261 RRMedicare PIN
FLP41389Medicare UPIN
FLY0245MMedicare PIN
FLY0245AMedicare PIN