Provider Demographics
NPI:1386287217
Name:MACKEY, KELLY JEAN (APRN)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEAN
Last Name:MACKEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:HINCKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:68 DIAL AVE
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-4737
Mailing Address - Country:US
Mailing Address - Phone:407-430-2379
Mailing Address - Fax:
Practice Address - Street 1:525 TECHNOLOGY PARK STE 109
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-7107
Practice Address - Country:US
Practice Address - Phone:407-647-2346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004725363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily