Provider Demographics
NPI:1255586475
Name:ANDERSON, KELLY MARIE (CNA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 17TH CT
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33477-9089
Mailing Address - Country:US
Mailing Address - Phone:561-427-4883
Mailing Address - Fax:
Practice Address - Street 1:1720 17TH CT
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477-9089
Practice Address - Country:US
Practice Address - Phone:561-427-4883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA174713376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide