Provider Demographics
NPI:1104435999
Name:KELLY, JULIE MARIE (MSN, APRN, NP-C)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSN, APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8815
Mailing Address - Country:US
Mailing Address - Phone:727-526-9135
Mailing Address - Fax:727-526-4346
Practice Address - Street 1:4105 49TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-5711
Practice Address - Country:US
Practice Address - Phone:727-528-6900
Practice Address - Fax:727-526-0753
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11019613363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114460100Medicaid