Provider Demographics
NPI:1447919386
Name:KELLY, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:KELLY
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 1:6265 OLD WATER OAK RD UNIT 203
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-4155
Mailing Address - Country:US
Mailing Address - Phone:850-408-7326
Mailing Address - Fax:
Practice Address - Street 1:6265 OLD WATER OAK RD UNIT 203
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-4155
Practice Address - Country:US
Practice Address - Phone:850-408-7326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH25888124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist