Provider Demographics
NPI:1013256338
Name:RAUCH, KELLY LYNN (FNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:RAUCH
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27810 SUMMERGATE BLVD
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6919
Mailing Address - Country:US
Mailing Address - Phone:813-388-2948
Mailing Address - Fax:813-388-6827
Practice Address - Street 1:325 CLYDE MORRIS BLVD STE 400
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8185
Practice Address - Country:US
Practice Address - Phone:386-671-0600
Practice Address - Fax:386-677-9710
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4811363LF0000X
FLAPRN11036937363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ213215OtherMEDICAID
AZ787564Medicaid