Provider Demographics
NPI:1568989317
Name:THATCHER, KELLY LEE (ARNP-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LEE
Last Name:THATCHER
Suffix:
Gender:F
Credentials:ARNP-C
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 10744
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-8744
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-266-4943
Practice Address - Street 1:3001 W DR MARTIN LUTHER KING JR BLVD FL 1
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607
Practice Address - Country:US
Practice Address - Phone:813-870-4619
Practice Address - Fax:813-554-8956
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9221346163WP0200X
FLARNP9221346363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023380000Medicaid