Provider Demographics
NPI:1790156164
Name:TUCKER, KELLY C (ARNP)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:C
Last Name:TUCKER
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 1:800 N MAITLAND AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4499
Mailing Address - Country:US
Mailing Address - Phone:407-660-7150
Mailing Address - Fax:407-660-7108
Practice Address - Street 1:800 N MAITLAND AVE STE 101
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4499
Practice Address - Country:US
Practice Address - Phone:407-660-7150
Practice Address - Fax:407-660-7108
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9199348363LF0000X
FLAPRN9199348363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015878700Medicaid