Provider Demographics
NPI:1306304910
Name:KELLY, BETHSAIDA JYN (RN, JD)
Entity type:Individual
Prefix:MRS
First Name:BETHSAIDA
Middle Name:JYN
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2768 RUNNING SPRINGS LOOP
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-9633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2768 RUNNING SPRINGS LOOP
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9633
Practice Address - Country:US
Practice Address - Phone:305-776-6273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9349334163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse