Provider Demographics
NPI:1285777565
Name:KELLEY, KRISTINA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-821-8038
Mailing Address - Fax:813-974-0483
Practice Address - Street 1:42002 E FOWLER AVENUE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-2715
Practice Address - Country:US
Practice Address - Phone:813-821-8038
Practice Address - Fax:813-974-0483
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA21795235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY911WOtherBCBS
FL119545200Medicaid