1164908604 NPI number — KELSEY TAYLOR HARTMANN APRN

Table of content: KELSEY TAYLOR HARTMANN APRN (NPI 1164908604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164908604 NPI number — KELSEY TAYLOR HARTMANN APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARTMANN
Provider First Name:
KELSEY
Provider Middle Name:
TAYLOR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLOUGHBY
Provider Other First Name:
KELSEY
Provider Other Middle Name:
TAYLOR
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164908604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 CRANDON BLVD
Provider Second Line Business Mailing Address:
STE 212
Provider Business Mailing Address City Name:
KEY BISCAYNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-361-6232
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 CRANDON BLVD
Provider Second Line Business Practice Location Address:
STE 212
Provider Business Practice Location Address City Name:
KEY BISCAYNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-361-6232
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  9483863 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 9483863 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100458600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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