Provider Demographics
NPI:1285729442
Name:KELLY, EILEEN (ARNP)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:KELLY
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 1:1403 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1000
Mailing Address - Country:US
Mailing Address - Phone:407-322-3096
Mailing Address - Fax:407-321-5655
Practice Address - Street 1:1403 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 202
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1000
Practice Address - Country:US
Practice Address - Phone:407-322-3096
Practice Address - Fax:407-321-5655
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2778312363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S55803Medicare UPIN