Provider Demographics
NPI:1144292822
Name:LATIMER, KELLY MAYA (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MAYA
Last Name:LATIMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 CREEKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4956
Mailing Address - Country:US
Mailing Address - Phone:904-213-8838
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL JACKSONVILLE
Practice Address - Street 2:2080 CHILD STREET
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-0001
Practice Address - Country:US
Practice Address - Phone:904-542-7977
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101223148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine