Provider Demographics
NPI:1831414804
Name:KOMISARUK, KELLY LEAH (MED)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEAH
Last Name:KOMISARUK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LEAH
Other - Last Name:KOMISARUK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5030 HARTWELL CT
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-7936
Mailing Address - Country:US
Mailing Address - Phone:321-388-2924
Mailing Address - Fax:407-358-5210
Practice Address - Street 1:5030 HARTWELL CT
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34771-7936
Practice Address - Country:US
Practice Address - Phone:321-388-2924
Practice Address - Fax:407-358-5210
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-02
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6954235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist