Provider Demographics
NPI:1821206566
Name:PRENTICE, KELLEY THOMASON (ARNP)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:THOMASON
Last Name:PRENTICE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:C
Other - Last Name:THOMASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:3208 CHIQUITA BLVD S STE 110
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-4267
Mailing Address - Country:US
Mailing Address - Phone:239-574-8463
Mailing Address - Fax:239-574-8491
Practice Address - Street 1:3208 CHIQUITA BLVD S STE 110
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-4267
Practice Address - Country:US
Practice Address - Phone:239-574-8463
Practice Address - Fax:239-574-8491
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9220789363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004202100Medicaid
FLAD942ZMedicare PIN