Provider Demographics
NPI:1871951475
Name:BECK, KELLEY JEAN
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:JEAN
Last Name:BECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:JEAN
Other - Last Name:RAYBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PSC 9
Mailing Address - Street 2:BOX 1222
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09123-9998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52D MEDICAL GROUP
Practice Address - Street 2:UNIT 3690
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09126-3690
Practice Address - Country:US
Practice Address - Phone:314-452-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9390515363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL206CXOtherBCBSFL
FL016773000Medicaid
FL016773000Medicaid