Provider Demographics
NPI:1306036074
Name:TOMASELLI, KELLY L (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:TOMASELLI
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616-102 W CAPE CORAL PKWY
Mailing Address - Street 2:PMB 125
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1616 CAPE CORAL PKWY W STE 102
Practice Address - Street 2:PMB 125
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-8911
Practice Address - Country:US
Practice Address - Phone:315-723-7279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 19521225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant