Basic Information
| Provider Information | |||||||||
| NPI: | 1861825127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 963 TOWN CENTER DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ORANGE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327638254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867749880 | ||||||||
| FaxNumber: | 3867742898 | ||||||||
| Practice Location | |||||||||
| Address1: | 963 TOWN CENTER DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ORANGE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327638254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867749880 | ||||||||
| FaxNumber: | 3867742898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2013 | ||||||||
| LastUpdateDate: | 05/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02004368 | 01 | AMERIGROUP | OTHER | OO9981300 | 05 | FL | MEDICAID |