Provider Demographics
NPI:1144663758
Name:KELLY, CHARLIE N (ARNP-BC)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:N
Last Name:KELLY
Suffix:
Gender:F
Credentials:ARNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4517
Mailing Address - Country:US
Mailing Address - Phone:850-785-1517
Mailing Address - Fax:
Practice Address - Street 1:70 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4517
Practice Address - Country:US
Practice Address - Phone:850-785-1517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-12
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9266192363L00000X
FL9266192363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner