Provider Demographics
NPI:1629447552
Name:WATSON, KELLY CONWAY (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:CONWAY
Last Name:WATSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12317 SOARING FLIGHT DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-0784
Mailing Address - Country:US
Mailing Address - Phone:904-881-8677
Mailing Address - Fax:
Practice Address - Street 1:12317 SOARING FLIGHT DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-0784
Practice Address - Country:US
Practice Address - Phone:904-881-8677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9348566363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003169318AMedicaid
FL015846600Medicaid
FLII429ZMedicare PIN