Provider Demographics
NPI:1104161488
Name:HUSSEY, KELLY RUTH (PA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RUTH
Last Name:HUSSEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 E FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4808
Mailing Address - Country:US
Mailing Address - Phone:813-396-0751
Mailing Address - Fax:
Practice Address - Street 1:13330 USF LAUREL DR
Practice Address - Street 2:5TH FLOOR
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6601
Practice Address - Country:US
Practice Address - Phone:813-396-0755
Practice Address - Fax:813-905-9829
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106636363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007255400Medicaid
FLY0EC2OtherBLUE CROSS BLUE SHIELD
FL007255400Medicaid