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Provider Information for 1649719915

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know

KELLY BOARD ARNP

Other Name:   KELLY GILLIAM
Gender: FEMALE

Individual NPI: 1649719915

Calendar   Last Updated:  2020-09-03
  Certification Date:  2020-09-03

Details

Name Value
NPI 1649719915
Enumeration Date 2017-02-19
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 10051 5TH ST N STE 200
ST PETERSBURG, FL 33702-2211
United States

Phone: 727-824-0780 | Fax: 727-568-6011
View Map External Link
Primary Practice Address 1460 BELTREES ST STE 1
DUNEDIN, FL 34698-8353
United States

Phone: 727-736-5120 | Fax: 727-734-3653
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Other DEA FL MB4257398
MEDICAID FL 024999700
Taxonomy
Primary Taxonomy Selected Taxonomy State License Number
Yes 363LA2200X - Nurse Practitioner Adult Health MI 4704272053