Basic Information
Provider Information | |||||||||
NPI: | 1740460930 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KELSEY | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 807 S ORLANDO AVE | ||||||||
Address2: | SUITE C | ||||||||
City: | WINTER PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 327894870 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4075152212 | ||||||||
FaxNumber: | 4075390469 | ||||||||
Practice Location | |||||||||
Address1: | 4100 METRIC DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | WINTER PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 327926837 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4076818720 | ||||||||
FaxNumber: | 4076818729 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/06/2007 | ||||||||
LastUpdateDate: | 04/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9191787 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 308888000 | 05 | FL |   | MEDICAID |