Provider Demographics
NPI:1396251054
Name:ANDERSON, KELLY MARIE (APRN, PMHNP-BC)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7014 SAN JOSE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-3422
Mailing Address - Country:US
Mailing Address - Phone:904-904-0690
Mailing Address - Fax:
Practice Address - Street 1:4500 SALISBURY RD STE 420
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0959
Practice Address - Country:US
Practice Address - Phone:904-800-6116
Practice Address - Fax:904-337-4724
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11014261363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty