Provider Demographics
NPI:1093511479
Name:LO, KELLY (CAA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LO
Suffix:
Gender:
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19060 TALON WAY
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-2446
Mailing Address - Country:US
Mailing Address - Phone:317-410-6612
Mailing Address - Fax:
Practice Address - Street 1:1309 N FLAGLER DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-3406
Practice Address - Country:US
Practice Address - Phone:954-838-2371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1048367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant