Provider Demographics
NPI:1710327101
Name:BURRISS, KELLY A (MBA)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:BURRISS
Suffix:
Gender:F
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10609 LIBERTY BELL DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3663
Mailing Address - Country:US
Mailing Address - Phone:813-334-0663
Mailing Address - Fax:813-364-1740
Practice Address - Street 1:10609 LIBERTY BELL DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3663
Practice Address - Country:US
Practice Address - Phone:813-334-0663
Practice Address - Fax:813-364-1740
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009351300Medicaid