Provider Demographics
NPI:1619606233
Name:HANNAHAN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HANNAHAN
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:PO BOX 622168
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32762-2168
Mailing Address - Country:US
Mailing Address - Phone:954-610-8420
Mailing Address - Fax:
Practice Address - Street 1:2959 ALAFAYA TRL STE 121
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9482
Practice Address - Country:US
Practice Address - Phone:407-986-1360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11020170363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health