Provider Demographics
NPI:1679820633
Name:LEGGE, KELLY ANNE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANNE
Last Name:LEGGE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANNE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:2675 WINKLER AVE FL 2FLOOR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:21297 OLEAN BLVD STE A
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6704
Practice Address - Country:US
Practice Address - Phone:855-979-5700
Practice Address - Fax:941-629-5049
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2886892363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007406600Medicaid
FLGP595YMedicare PIN