Provider Demographics
NPI:1801447800
Name:KELLY, WARRENETTE YVETTE
Entity type:Individual
Prefix:
First Name:WARRENETTE
Middle Name:YVETTE
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 1:206 SW WHITETAIL CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-3729
Mailing Address - Country:US
Mailing Address - Phone:386-438-9584
Mailing Address - Fax:
Practice Address - Street 1:619 S MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5808
Practice Address - Country:US
Practice Address - Phone:386-755-3016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL132591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical