Basic Information
Provider Information | |||||||||
NPI: | 1891140471 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WARD | ||||||||
FirstName: | KELLEY | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NAUS | ||||||||
OtherFirstName: | KELLEY | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1500 SW 1ST AVE | ||||||||
Address2: |   | ||||||||
City: | OCALA | ||||||||
State: | FL | ||||||||
PostalCode: | 344716504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4079750412 | ||||||||
FaxNumber: | 4079750413 | ||||||||
Practice Location | |||||||||
Address1: | 101 MANNING DR | ||||||||
Address2: |   | ||||||||
City: | CHAPEL HILL | ||||||||
State: | NC | ||||||||
PostalCode: | 275144220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9199667890 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2016 | ||||||||
LastUpdateDate: | 03/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME138706 | FL | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 2021-03215 | NC | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 103194600 | 05 | FL |   | MEDICAID |