Provider Demographics
NPI:1366951600
Name:KELLY, LETICIA (CERTIFIED NURSES ASS)
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:CERTIFIED NURSES ASS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 SW HUNNICUT AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-7007
Mailing Address - Country:US
Mailing Address - Phone:561-306-9275
Mailing Address - Fax:
Practice Address - Street 1:1535 SW HUNNICUT AVE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-7007
Practice Address - Country:US
Practice Address - Phone:561-306-9275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA109443374U00000X, 376K00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCNA109443Medicaid