Provider Demographics
NPI:1285624932
Name:COLE, KELLY LYNN (PAC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:COLE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 NW 57TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4482
Mailing Address - Country:US
Mailing Address - Phone:352-519-5430
Mailing Address - Fax:352-333-6249
Practice Address - Street 1:1034 NW 57TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4482
Practice Address - Country:US
Practice Address - Phone:352-519-5430
Practice Address - Fax:352-333-6249
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103309363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292173100Medicaid
FLQ49703Medicare UPIN
FLU5368AMedicare ID - Type Unspecified
FL292173100Medicaid