Provider Demographics
NPI:1609160886
Name:PAWUL, KELLY
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:PAWUL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15550 SAN CARLOS BLVD
Mailing Address - Street 2:#0196
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-2550
Mailing Address - Country:US
Mailing Address - Phone:239-433-2631
Mailing Address - Fax:
Practice Address - Street 1:15550 SAN CARLOS BLVD
Practice Address - Street 2:#0196
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-2550
Practice Address - Country:US
Practice Address - Phone:239-433-2631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-05
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39440183500000X
OHRPH. 03226091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist