Provider Demographics
NPI:1588101109
Name:HANKINS, KELLY MARIE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:HANKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SUMMER BREEZE WAY
Mailing Address - Street 2:APARTMENT 113
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-1834
Mailing Address - Country:US
Mailing Address - Phone:904-829-7362
Mailing Address - Fax:
Practice Address - Street 1:200 SUMMER BREEZE WAY
Practice Address - Street 2:APARTMENT 113
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-1834
Practice Address - Country:US
Practice Address - Phone:904-829-7362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029963400Medicaid