Provider Demographics
NPI:1669581161
Name:FLORIANO, KELLY RAE (PA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RAE
Last Name:FLORIANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:RAE
Other - Last Name:ROCHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-0549
Mailing Address - Country:US
Mailing Address - Phone:906-774-1313
Mailing Address - Fax:906-776-5639
Practice Address - Street 1:1711 S STEPHENSON AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3639
Practice Address - Country:US
Practice Address - Phone:906-776-5860
Practice Address - Fax:906-776-5833
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003478363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5220024OtherBCBSM PIN
MI381875190OtherTAX IDENTIFICATION NUMBER
MI5601003478OtherPHYSICIANS ASSIST LICENSE
MI0852915090OtherBCBS PIN NUMBER
MIP01025991OtherRR MEDICARE
MIMR0945571OtherDEA REGISTRATION NUMBER
MIP01025991OtherRR MEDICARE
MI381875190OtherTAX IDENTIFICATION NUMBER
MIM02890019Medicare PIN
MI5601003478OtherPHYSICIANS ASSIST LICENSE