Provider Demographics
NPI:1811459399
Name:PARKER, KELLY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:PARKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:38135 MARKET SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:352-567-0188
Mailing Address - Fax:813-355-5101
Practice Address - Street 1:2100 VIA BELLA BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-5429
Practice Address - Country:US
Practice Address - Phone:813-712-5718
Practice Address - Fax:813-355-5029
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025795207QA0505X, 363AM0700X
FLPA9117316363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine