Provider Demographics
NPI:1205351020
Name:LARREA, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LARREA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15280 NW 79TH CT STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5873
Mailing Address - Country:US
Mailing Address - Phone:305-558-3724
Mailing Address - Fax:786-907-4485
Practice Address - Street 1:160 E LAKE HOWARD DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-3155
Practice Address - Country:US
Practice Address - Phone:863-299-1251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-14
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2679363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108977700Medicaid