Provider Demographics
NPI:1710341557
Name:TRAYLOR, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:TRAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4348 SOUTHPOINT BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-0986
Mailing Address - Country:US
Mailing Address - Phone:904-281-1915
Mailing Address - Fax:904-281-1119
Practice Address - Street 1:4348 SOUTHPOINT BLVD
Practice Address - Street 2:STE 100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0986
Practice Address - Country:US
Practice Address - Phone:904-281-1915
Practice Address - Fax:904-981-1119
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9258734363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily