Provider Demographics
NPI:1972593820
Name:WELLS, KELLI TICE (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:TICE
Last Name:WELLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 W FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-1107
Mailing Address - Country:US
Mailing Address - Phone:850-595-6501
Mailing Address - Fax:
Practice Address - Street 1:1295 W FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1107
Practice Address - Country:US
Practice Address - Phone:850-595-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82944208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009978895Medicaid
AL59176263OtherBLUE CROSS BLUE SHIELD
FL262522900Medicaid
FL06241OtherBLUE CROSS BLUE SHIELD
P00195990OtherMEDICARE RAILROAD
7804499OtherAETNA
AL59176263OtherBLUE CROSS BLUE SHIELD
FL06241VMedicare ID - Type Unspecified