Provider Demographics
NPI:1811510894
Name:KELLY, SEAN (RN)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-5751
Mailing Address - Country:US
Mailing Address - Phone:561-577-7925
Mailing Address - Fax:
Practice Address - Street 1:530 VIRGINIA DR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-5751
Practice Address - Country:US
Practice Address - Phone:561-577-7925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-25
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9188756163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty