Provider Demographics
NPI:1063628402
Name:KELLY, LYNN W (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:W
Last Name:KELLY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7258 WINBERT DR
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-1456
Mailing Address - Country:US
Mailing Address - Phone:716-694-4179
Mailing Address - Fax:
Practice Address - Street 1:7258 WINBERT DR
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-1456
Practice Address - Country:US
Practice Address - Phone:716-694-4179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6403-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist