Provider Demographics
NPI:1174265227
Name:THERIAULT, KELSEY V (DO)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:V
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12225 28TH ST N STE B
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1860
Mailing Address - Country:US
Mailing Address - Phone:727-561-4303
Mailing Address - Fax:727-561-9299
Practice Address - Street 1:12225 28TH ST N STE B
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1860
Practice Address - Country:US
Practice Address - Phone:727-561-4303
Practice Address - Fax:727-561-9299
Is Sole Proprietor?:No
Enumeration Date:2022-04-10
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS21707207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program