Provider Demographics
NPI:1548738248
Name:COLLURA, KELLY ANN (APRN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:COLLURA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 TAVISTOCK LAKES BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7592
Mailing Address - Country:US
Mailing Address - Phone:321-380-1411
Mailing Address - Fax:407-286-4515
Practice Address - Street 1:2185 CHENEY HWY STE A
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-6700
Practice Address - Country:US
Practice Address - Phone:321-269-9800
Practice Address - Fax:321-269-7082
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-12
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9404112363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106050000Medicaid
FLMF482OtherMEDICARE