Provider Demographics
NPI:1932398757
Name:WILSON, KELLEY ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:ANNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3101 W DR MLK BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6210
Mailing Address - Country:US
Mailing Address - Phone:813-800-5252
Mailing Address - Fax:813-800-5252
Practice Address - Street 1:3101 W DR MLK BLVD STE 110
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6210
Practice Address - Country:US
Practice Address - Phone:813-800-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1055652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006777700Medicaid