Provider Demographics
NPI:1598326571
Name:FERRARA, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FERRARA
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 1:1890 LPGA BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7131
Mailing Address - Country:US
Mailing Address - Phone:386-231-3284
Mailing Address - Fax:
Practice Address - Street 1:1890 LPGA BLVD STE 140
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7131
Practice Address - Country:US
Practice Address - Phone:386-231-3284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11002839363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner