Provider Demographics
NPI:1366175036
Name:ROBERTS, KELLY ANN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11302 SW 244TH TER
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-4629
Mailing Address - Country:US
Mailing Address - Phone:305-213-5053
Mailing Address - Fax:
Practice Address - Street 1:3100 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3009
Practice Address - Country:US
Practice Address - Phone:305-515-5425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2022-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11012159363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner