Provider Demographics
NPI:1790319994
Name:KELLY, COREEN
Entity type:Individual
Prefix:
First Name:COREEN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1862 SILVER FERN RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6741
Mailing Address - Country:US
Mailing Address - Phone:518-409-3502
Mailing Address - Fax:
Practice Address - Street 1:1430 MASON AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-4551
Practice Address - Country:US
Practice Address - Phone:386-274-2000
Practice Address - Fax:386-274-2009
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11006345363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner