Provider Demographics
NPI:1992120141
Name:JENNINGS, KELLY LEEDY (NP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEEDY
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICHOLS
Other - Last Name:LEEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:701 N CLAYTON ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-3165
Mailing Address - Country:US
Mailing Address - Phone:302-421-4334
Mailing Address - Fax:
Practice Address - Street 1:303 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-425-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG-0000737363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily