Provider Demographics
NPI:1013126853
Name:LELLI, KATRINA L (RPAC)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:L
Last Name:LELLI
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-419-4833
Practice Address - Street 1:2398 SE OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-3310
Practice Address - Country:US
Practice Address - Phone:772-419-4834
Practice Address - Fax:772-419-4833
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02522278Medicaid
FL1PKD4OtherFLORIDA BLUE
P00819028OtherRAILROAD MEDICARE PIN
P00819028OtherRAILROAD MEDICARE PIN