Provider Demographics
NPI:1336920875
Name:WOMBLES, KELLY CHRISTINE (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CHRISTINE
Last Name:WOMBLES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14563 EVANS RANCH RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-9775
Mailing Address - Country:US
Mailing Address - Phone:863-651-6366
Mailing Address - Fax:
Practice Address - Street 1:802 W DR MARTIN LUTHER KING JR BLVD STE D
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-5105
Practice Address - Country:US
Practice Address - Phone:813-754-1496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11028684363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty