Provider Demographics
NPI:1407924558
Name:KELLEY, LARISA COYE (MD)
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:COYE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4477 MEDICAL CENTER WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3286
Mailing Address - Country:US
Mailing Address - Phone:561-471-1808
Mailing Address - Fax:
Practice Address - Street 1:4477 MEDICAL CENTER WAY
Practice Address - Street 2:SUITE A
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3286
Practice Address - Country:US
Practice Address - Phone:561-471-1808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98953207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAT819ZMedicare PIN
MAG04086Medicare UPIN