Provider Demographics
NPI:1568190221
Name:KELLEY, MADELEINE RAE (APRN)
Entity Type:Individual
Prefix:
First Name:MADELEINE
Middle Name:RAE
Last Name:KELLEY
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 1:459 SE HERNANDO AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5977
Mailing Address - Country:US
Mailing Address - Phone:352-356-3037
Mailing Address - Fax:
Practice Address - Street 1:103 SE 3RD ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:FL
Practice Address - Zip Code:32693-3247
Practice Address - Country:US
Practice Address - Phone:352-577-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11021350363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health