Provider Demographics
NPI:1922664762
Name:GRADY, KELLI KRISTIANA (APRN)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:KRISTIANA
Last Name:GRADY
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 1:2023 TOURNAMENT DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-2022
Mailing Address - Country:US
Mailing Address - Phone:813-230-0455
Mailing Address - Fax:
Practice Address - Street 1:4880 N HIGHWAY 19A STE 200
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2018
Practice Address - Country:US
Practice Address - Phone:352-589-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001066363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics