Provider Demographics
NPI:1861780827
Name:KELLY, DIANA (ARNP)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 MOSAIC FOREST DR
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-5568
Mailing Address - Country:US
Mailing Address - Phone:813-505-9519
Mailing Address - Fax:
Practice Address - Street 1:1712 MOSAIC FOREST DR
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-5568
Practice Address - Country:US
Practice Address - Phone:813-505-9519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9192144363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner