Provider Demographics
NPI:1336324110
Name:KELLEY, KIMBERLYN NANETTA (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:KIMBERLYN
Middle Name:NANETTA
Last Name:KELLEY
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2916 HABANA WAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7108
Mailing Address - Country:US
Mailing Address - Phone:813-846-9788
Mailing Address - Fax:
Practice Address - Street 1:8517 BROKEN WILLOW CT
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647
Practice Address - Country:US
Practice Address - Phone:813-846-9788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-30
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10652225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist