Provider Demographics
NPI:1740207497
Name:KEVITT, KELLY (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:KEVITT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:STACY-HAINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:701 E SR 50
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-3165
Mailing Address - Country:US
Mailing Address - Phone:352-242-9023
Mailing Address - Fax:
Practice Address - Street 1:701 E SR 50
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-3165
Practice Address - Country:US
Practice Address - Phone:352-242-9023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9178446363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2007009890OtherAMERICAN NURSES CREDENTIALING CENTER
FL3080927-00Medicaid
FL2007009890OtherAMERICAN NURSES CREDENTIALING CENTER
FL3080927-00Medicaid