Basic Information
| Provider Information | |||||||||
| NPI: | 1871009712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOVE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 W UNDERWOOD ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076496884 | ||||||||
| FaxNumber: | 4072457059 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 W UNDERWOOD ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076496884 | ||||||||
| FaxNumber: | 4072457059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN9388691 | FL | N | Nursing Service Providers | Registered Nurse | 363L00000X | F10170148 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | ARNP9388691 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 023529200 | 05 | FL | MEDICAID |