Provider Demographics
NPI:1730541509
Name:SCOTT, KELLEY
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4161 TAMIAMI TRAIL
Mailing Address - Street 2:SUITE 704
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33953-9283
Mailing Address - Country:US
Mailing Address - Phone:941-625-1110
Mailing Address - Fax:941-625-0552
Practice Address - Street 1:4161 TAMIAMI TRAIL
Practice Address - Street 2:SUITE 704
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33953-9283
Practice Address - Country:US
Practice Address - Phone:941-625-1110
Practice Address - Fax:941-625-0552
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26328171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor