1841294709 NPI number — MS. VENDA KELLEY ARNP

Table of content: MS. VENDA KELLEY ARNP (NPI 1841294709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841294709 NPI number — MS. VENDA KELLEY ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
VENDA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841294709
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3434 HANCOCK BRIDGE PKWY
Provider Second Line Business Mailing Address:
STE. 301
Provider Business Mailing Address City Name:
NORTH FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33903-7094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-856-3774
Provider Business Mailing Address Fax Number:
239-599-2612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2450 TAMIAMI TRL
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33952-3922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-856-3774
Provider Business Practice Location Address Fax Number:
239-599-2612
Provider Enumeration Date:
06/09/2005

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:  ARNP9429926 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 3672P , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2237571 . This is a "CCN" identifier . This identifiers is of the category "OTHER".
  • Identifier: C60195 . This is a "CUMBERLAND HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000226588 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 78007788 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: A574 . This is a "BC/BS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 017319200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6EFGA . This is a "BLUS CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1191652 . This is a "CHA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 500026005 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 017319200 . 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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