Provider Demographics
NPI:1710483771
Name:CRAGETT- KNOWLES, KELLY J (APRN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:CRAGETT- KNOWLES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:J
Other - Last Name:CRAGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:1396 WHISPER CIR
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-1204
Practice Address - Country:US
Practice Address - Phone:863-385-1244
Practice Address - Fax:863-385-6086
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9212525363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108840200Medicaid