Provider Demographics
NPI:1699947259
Name:MERRIMAN, KELLY ELIZABETH (LMT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ELIZABETH
Last Name:MERRIMAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10680 SQUALL LINE RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-2157
Mailing Address - Country:US
Mailing Address - Phone:850-319-2200
Mailing Address - Fax:
Practice Address - Street 1:11325 LILLIAN HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32506-8330
Practice Address - Country:US
Practice Address - Phone:850-319-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-24
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 37541171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2144OtherBLUE CROSS BLUE SHIELD