Provider Demographics
NPI:1558056671
Name:KELLY, MANDY JO (DNP, APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:JO
Last Name:KELLY
Suffix:
Gender:F
Credentials:DNP, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 GRANT PL
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5600
Mailing Address - Country:US
Mailing Address - Phone:314-856-2275
Mailing Address - Fax:
Practice Address - Street 1:725 N 12TH AVE BLDG B
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-8752
Practice Address - Country:US
Practice Address - Phone:863-494-1242
Practice Address - Fax:863-491-0466
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023006955363LP0808X
FLAPRN11025764363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health