NPIMap

Organization Active NPI

Florida Atlantic University

  • Gerontology Nurse Practitioner
  • Boca Raton, FL
National Provider Identifier
1164591954
Registry record updated Dec 15, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Gerontology Nurse PractitionerTaxonomy code 363LG0600X
Legal business name
FLORIDA ATLANTIC UNIVERSITY
Practice address
777 Glades Rd
BLDG Az-79
Boca Raton, FL 33431-6424
Phone
(561) 297-0502
Fax
(561) 297-0505
NPI assigned
Nov 7, 2006
Organization subpart
Yes
Parent organization
FLORIDA ATLANTIC UNIVERSITYAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 15, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Louisa Pontiroli-Kelly
Title
Authorized Official
Phone
(561) 297-2897

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical NeuropsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103G00000X
Clinical PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC0700X
Gerontology Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LG0600X Primary

Addresses

Primary practice location

777 Glades Rd
BLDG Az-79
Boca Raton, FL 33431-6424

Mailing address

777 Glades Rd BLDG Az-79
Boca Raton, FL 33431-6424
Phone (561) 297-0502

Other names 1

  • Memory and Wellness Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040511001511 FL Part B Supplier - Clinic/Group Practice 8921097171 Receives reassigned benefits from 30 practitioners
4 other NPIs on this enrollment
Practice locations: West Palm Beach, FL; Boca Raton, FL

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 4

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D0993887Fau Memory & Wellness Center777 Glades Rd BLDG Az-79, Boca Raton, FL 33431Certificate of waiverJan 12, 2027

National Provider Directory

National Provider Directory
Tax ID family
Board of Trustees of Florida Atlantic University8 organizations share this tax ID, including this one
Part of
Board of Trustees of Florida Atlantic University

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

Locations

880 NW 13th St
Ste 4004
Boca Raton, FL 33486

880 NW 13th St
Ste 400
Boca Raton, FL 33486
Phone (561) 297-4814

880 NW 13th St
Fl 4
Boca Raton, FL 33486
Phone (561) 566-5328

777 Glades Rd
Rm 240
Boca Raton, FL 33431
Phone (561) 297-3512

777 Glades Rd
#8W240
Boca Raton, FL 33431
Phone (561) 297-3512

777 Glades Rd
Bldg ME104
Boca Raton, FL 33431

777 Glades Rd
Bldg 8W
Boca Raton, FL 33431

3200 College Ave
Bldg SDBC54
Davie, FL 33314

5353 Parkside Dr
Bldg SRMC3
Jupiter, FL 33458

720 8th St
West Palm Beach, FL 33401
Phone (561) 803-8880

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Community Health CenterWest Palm Beach, FL, CCN 681903 Federally qualified health center Other Jan 1, 2022

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 46

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 46

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162857600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1765756800000",
    "number": "1164591954",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "777 GLADES RD BLDG AZ-79",
            "city": "BOCA RATON",
            "state": "FL",
            "postal_code": "334316424",
            "telephone_number": "561-297-0502",
            "fax_number": "561-297-0505"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "777 GLADES RD",
            "address_2": "BLDG AZ-79",
            "city": "BOCA RATON",
            "state": "FL",
            "postal_code": "334316424",
            "telephone_number": "561-297-0502",
            "fax_number": "561-297-0505"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FLORIDA ATLANTIC UNIVERSITY",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "FLORIDA ATLANTIC UNIVERSITY",
        "enumeration_date": "2006-11-07",
        "last_updated": "2025-12-15",
        "certification_date": "2025-12-15",
        "status": "A",
        "authorized_official_last_name": "PONTIROLI-KELLY",
        "authorized_official_first_name": "LOUISA",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "561-297-2897"
    },
    "taxonomies": [
        {
            "code": "103G00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Clinical Neuropsychologist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LG0600X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Gerontology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Memory and Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Memory and Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Boca Raton, FL

Sources for this page

Verify at the official NPI Registry.