Provider Demographics
NPI:1134675119
Name:LAKE, KELSEY (DPT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 RIVER REACH RD
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-8184
Mailing Address - Country:US
Mailing Address - Phone:301-767-7436
Mailing Address - Fax:
Practice Address - Street 1:784 BLANDING BLVD STE 108
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7724
Practice Address - Country:US
Practice Address - Phone:904-264-2636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist