Provider Demographics
NPI:1124614789
Name:O'BRIEN, KELLY MARIE (ARNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4663 AUTUMNDALE DR
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-1394
Mailing Address - Country:US
Mailing Address - Phone:850-776-3325
Mailing Address - Fax:
Practice Address - Street 1:4663 AUTUMNDALE DR
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1394
Practice Address - Country:US
Practice Address - Phone:850-776-3325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9196840163WC0400X
FL11011201363LF0000X
FLAPRN11011201363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily