Provider Demographics
NPI:1508482456
Name:SIMEON, KELLY
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:
Last Name:SIMEON
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:PO BOX 5941
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33083-5941
Mailing Address - Country:US
Mailing Address - Phone:954-256-3673
Mailing Address - Fax:800-390-1648
Practice Address - Street 1:360 SE 12TH AVE APT 1
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-4449
Practice Address - Country:US
Practice Address - Phone:954-256-3673
Practice Address - Fax:800-390-1648
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLS550500732920172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver