Provider Demographics
NPI:1952761496
Name:KELLY, JOSSETTE
Entity Type:Individual
Prefix:MRS
First Name:JOSSETTE
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 1:4973 CREEKSIDE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-6465
Mailing Address - Country:US
Mailing Address - Phone:407-873-5109
Mailing Address - Fax:
Practice Address - Street 1:4973 CREEKSIDE PARK AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-6465
Practice Address - Country:US
Practice Address - Phone:407-873-5109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN3358862163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse