Provider Demographics
NPI:1639328537
Name:ROMANELLY, KELLY J
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:ROMANELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:ROMANELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:602 SW CABURN AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-7667
Mailing Address - Country:US
Mailing Address - Phone:812-239-1348
Mailing Address - Fax:
Practice Address - Street 1:3501 SE WILLOUGHBY BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-5059
Practice Address - Country:US
Practice Address - Phone:772-288-0304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0991657-NP363L00000X
MT139323363L00000X
IN71002642A363LF0000X
FLARNP9302217363LF0000X
FL11019552363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY03K0OtherBLUESHIELD
FL001888500Medicaid
CO57983216Medicaid
FLCV34ZOtherMEDICARE
CO420515YLA0Medicare PIN