Basic Information
| Provider Information | |||||||||
| NPI: | 1679820633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEGGE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2675 WINKLER AVE FL 2FLOOR | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339019342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21297 OLEAN BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339526704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8559795700 | ||||||||
| FaxNumber: | 9416295049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2012 | ||||||||
| LastUpdateDate: | 12/02/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP 2886892 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 007406600 | 05 | FL | MEDICAID |