Provider Demographics
NPI:1689843054
Name:BRENNER, KELLEY GRAYSON (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:GRAYSON
Last Name:BRENNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-6021
Mailing Address - Country:US
Mailing Address - Phone:407-891-3500
Mailing Address - Fax:407-892-3285
Practice Address - Street 1:3100 17TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-6021
Practice Address - Country:US
Practice Address - Phone:407-891-3500
Practice Address - Fax:407-892-3285
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002724363A00000X, 363AM0700X
FLPA-9107363363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant