Provider Demographics
NPI:1437497401
Name:KELLY, RITA A (APRN)
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-2755
Mailing Address - Fax:239-424-2756
Practice Address - Street 1:708 DEL PRADO BLVD S STE 6
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2661
Practice Address - Country:US
Practice Address - Phone:239-424-2755
Practice Address - Fax:239-424-2756
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000309364SM0705X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104321400Medicaid