Provider Demographics
NPI:1194949388
Name:KELLY, TRACY ANN (PA)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:TRACY
Other - Middle Name:ANN
Other - Last Name:BEVERLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3000 SW 148TH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-4169
Mailing Address - Country:US
Mailing Address - Phone:703-244-9469
Mailing Address - Fax:
Practice Address - Street 1:3000 SW 148TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-4169
Practice Address - Country:US
Practice Address - Phone:703-244-9469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA012000974246Z00000X
VA0110003365363A00000X
FLPA9105943363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical