Provider Demographics
NPI:1003680638
Name:LICONA, KELLY YURANI (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:YURANI
Last Name:LICONA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 NW 85TH CT APT 310
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33122-1961
Mailing Address - Country:US
Mailing Address - Phone:954-871-5045
Mailing Address - Fax:
Practice Address - Street 1:8200 NW 27TH ST STE 101
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33122-1902
Practice Address - Country:US
Practice Address - Phone:305-591-4181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT40976225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist