Provider Demographics
NPI:1760855183
Name:OLIVER, KELLIE (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:OLIVER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WINDERLEY PLACE
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-3801
Mailing Address - Country:US
Mailing Address - Phone:407-875-0555
Mailing Address - Fax:
Practice Address - Street 1:215 ACACIA RD
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-3801
Practice Address - Country:US
Practice Address - Phone:386-956-8973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9313212364SE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SE0003XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistEmergency