1437291747 NPI number — DR. CARLA DEE KELLY PHD

Table of content: DR. CARLA DEE KELLY PHD (NPI 1437291747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437291747 NPI number — DR. CARLA DEE KELLY PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
CARLA
Provider Middle Name:
DEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEE
Provider Other First Name:
CARLA
Provider Other Middle Name:
KELLY
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1437291747
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 S COOLIDGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-286-0320
Provider Business Mailing Address Fax Number:
813-207-0022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4100 W KENNEDY BLVD
Provider Second Line Business Practice Location Address:
#214
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-289-6502
Provider Business Practice Location Address Fax Number:
813-207-0022
Provider Enumeration Date:
02/13/2007

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: 103T00000X , with the licence number:  PY0002141 , 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: 00073171 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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