Provider Demographics
NPI:1881671634
Name:KELLY, STACEY ANN (APRN)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 W MONROE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-1177
Mailing Address - Country:US
Mailing Address - Phone:904-384-2240
Mailing Address - Fax:904-486-2314
Practice Address - Street 1:915 W MONROE ST STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1177
Practice Address - Country:US
Practice Address - Phone:904-384-2240
Practice Address - Fax:904-486-2314
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9205289363LA2100X, 363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01402890OtherRAILROAD MEDICARE
FLCU704ZMedicare PIN