Provider Demographics
NPI:1992279996
Name:SELETOS, COLLEEN O'KENNEDY (PA-C)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:O'KENNEDY
Last Name:SELETOS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:MARIE
Other - Last Name:O'KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2044 TRINITY OAKS BLVD
Mailing Address - Street 2:STE 220
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4406
Mailing Address - Country:US
Mailing Address - Phone:727-645-6900
Mailing Address - Fax:727-372-8989
Practice Address - Street 1:2044 TRINITY OAKS BLVD STE 220
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4406
Practice Address - Country:US
Practice Address - Phone:727-645-6900
Practice Address - Fax:727-372-8989
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9111933363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9111933OtherFLORIDA DEPARTMENT OF HEALTH