Provider Demographics
NPI:1760001044
Name:KERLEY, KAITLYN
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:KERLEY
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 1:221 MAIN ST N
Mailing Address - Street 2:APT 716
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10000 BAY PINES BLVD
Practice Address - Street 2:
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744-8200
Practice Address - Country:US
Practice Address - Phone:727-398-6661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-100807183500000X
TN46350183500000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN01241995OtherEDUCATION PURPOSE