Provider Demographics
NPI:1245265859
Name:BISSELL, KELLI M (ARNP)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:M
Last Name:BISSELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MISS
Other - First Name:KELLI
Other - Middle Name:MICHELE
Other - Last Name:HOOK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT OF PEDIATRICS
Mailing Address - Street 2:PO BOX 100296
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0296
Mailing Address - Country:US
Mailing Address - Phone:352-273-6563
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610
Practice Address - Country:US
Practice Address - Phone:352-273-6563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24166224363LP0200X
FLARNP9256044363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7003733OtherNC ACCESS
VA92535NOtherOPTIMA HEALTH
VA96630NOtherOPTIMA FAMILY CARE
VA96630NOtherFAMIS OPTIMA FAMILY CARE
FL003593100Medicaid
VA010188849Medicaid
VA7003733OtherNC MEDICAID
VA96630NOtherOPTIMA HEALTH PLAN
006033C38Medicare ID - Type Unspecified