Provider Demographics
NPI:1487048930
Name:ELLESON, KELLY M (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:ELLESON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:WILLIAMSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8931 COLONIAL CENTER DR STE 301
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-7809
Mailing Address - Country:US
Mailing Address - Phone:239-728-1021
Mailing Address - Fax:
Practice Address - Street 1:8931 COLONIAL CENTER DR STE 301
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7809
Practice Address - Country:US
Practice Address - Phone:239-539-8815
Practice Address - Fax:239-277-0729
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME146912208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty