Provider Demographics
NPI:1336267624
Name:KELLY, NICOLE
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:FILUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4465 GABRIELLA LN
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-6325
Mailing Address - Country:US
Mailing Address - Phone:407-619-6204
Mailing Address - Fax:407-671-1604
Practice Address - Street 1:155 LANDOVER PL
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4924
Practice Address - Country:US
Practice Address - Phone:407-830-7744
Practice Address - Fax:407-830-7926
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6608225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist