Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207YX0905X | Otolaryngology/Facial Plastic Surgery | PA2679 | FL |
NPI | 1205351020 |
---|---|
Provider Name | Kelly Larrea |
First Address | Miami Lakes, FL 33016-5861 |
Second Address | Winter Haven, FL 33881-3155 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/08/2017 |
Last Update Date | 24/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
108977700 | (05) | FL |