Basic Information
| Provider Information | |||||||||
| NPI: | 1396249652 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOEHLKE | ||||||||
| FirstName: | KELLEEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 4TH ST S UNIT 239 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202879988 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7550 43RD ST N | ||||||||
| Address2: | |||||||||
| City: | PINELLAS PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337813601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278248181 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2018 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | D95275 | MD | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | ME149899 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.