Provider Demographics
NPI:1790218634
Name:BALLETTI, KELLY KATHLEEN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KATHLEEN
Last Name:BALLETTI
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 1:135 SAN LORENZO AVE
Mailing Address - Street 2:SUITE #700
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-1524
Mailing Address - Country:US
Mailing Address - Phone:305-444-4979
Mailing Address - Fax:
Practice Address - Street 1:135 SAN LORENZO AVE
Practice Address - Street 2:SUITE #700
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-1524
Practice Address - Country:US
Practice Address - Phone:305-444-4979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9110317363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical