Provider Demographics
NPI:1649719915
Name:BOARD, KELLY (APRN, NP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BOARD
Suffix:
Gender:F
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:GILLIAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 211699
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-3699
Mailing Address - Country:US
Mailing Address - Phone:866-849-0692
Mailing Address - Fax:888-973-8821
Practice Address - Street 1:880 SW 145TH AVE STE 202
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-6171
Practice Address - Country:US
Practice Address - Phone:866-849-0692
Practice Address - Fax:888-973-8821
Is Sole Proprietor?:No
Enumeration Date:2017-02-19
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37319363LA2200X
SC29709363LA2200X
GAGAA-NP003047363LA2200X
AZ303204363LA2200X
IL209028496363LA2200X
NC5018989363LA2200X
MI4704272053363LA2200X
COCAPN.0101629363LA2200X
FLAPRN9482729363LA2200X
OH0033314363LA2200X
TX1102491363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024999700Medicaid
FL024999700Medicaid