Provider Demographics
NPI:1033939764
Name:MARTIN, KELLY MARIE (APRN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 NORMANDY RD
Mailing Address - Street 2:
Mailing Address - City:MADEIRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33708-2315
Mailing Address - Country:US
Mailing Address - Phone:954-849-0254
Mailing Address - Fax:
Practice Address - Street 1:455 PINELLAS ST STE 400
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3356
Practice Address - Country:US
Practice Address - Phone:727-445-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11035940363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily