Basic Information
| Provider Information | |||||||||
| NPI: | 1508384736 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | RENEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7218 SAMUEL IVY DR | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336196964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177561494 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13837 CIRCA CROSSING DR | ||||||||
| Address2: | |||||||||
| City: | LITHIA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335474382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136842663 | ||||||||
| FaxNumber: | 8166586222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2017 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.