Provider Demographics
NPI:1023705902
Name:SHEEHAN, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SHEEHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1768 SW 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-2139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1768 SW 22ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-2139
Practice Address - Country:US
Practice Address - Phone:305-206-4696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174200000XOther Service ProvidersMeals