Provider Demographics
NPI:1578788378
Name:KELLEY, JANET
Entity Type:Individual
Prefix:DR
First Name:JANET
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:JAN
Other - Middle Name:
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:3400 TAMIAMI TRL STE 103
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8102
Mailing Address - Country:US
Mailing Address - Phone:941-625-2667
Mailing Address - Fax:
Practice Address - Street 1:3400 TAMIAMI TRL STE 103
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8102
Practice Address - Country:US
Practice Address - Phone:941-625-2667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6944111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU29428Medicare UPIN