Provider Demographics
NPI:1902655756
Name:GARRISON, KELVIN YATON
Entity type:Individual
Prefix:
First Name:KELVIN
Middle Name:YATON
Last Name:GARRISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23134 NW 5TH PL
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669-3553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23134 NW 5TH PL
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:FL
Practice Address - Zip Code:32669-3553
Practice Address - Country:US
Practice Address - Phone:813-777-5092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171244666376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator