Provider Demographics
NPI:1790557965
Name:ANTHONY, KELLY J
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:ANTHONY
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 1:4486 ORLANDO AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34604-8017
Mailing Address - Country:US
Mailing Address - Phone:135-229-3612
Mailing Address - Fax:
Practice Address - Street 1:4486 ORLANDO AVE
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34604-8017
Practice Address - Country:US
Practice Address - Phone:135-229-3612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL239688376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker