Provider Demographics
NPI:1740024033
Name:MCSHANE, KELLY (PMHNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MCSHANE
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4479 ROCKY RIVER RD W FL 32224
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-8685
Mailing Address - Country:US
Mailing Address - Phone:386-295-3547
Mailing Address - Fax:
Practice Address - Street 1:4479 ROCKY RIVER RD W FL 32224
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-8685
Practice Address - Country:US
Practice Address - Phone:386-295-3547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11033535363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health