Provider Demographics
NPI:1346389483
Name:EDWARDS, KELLY ROXANNE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ROXANNE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:ROXANNE
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:701 W CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6015
Mailing Address - Country:US
Mailing Address - Phone:559-713-6806
Mailing Address - Fax:559-713-6809
Practice Address - Street 1:1150 W MORTON AVE STE B
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257
Practice Address - Country:US
Practice Address - Phone:559-782-1501
Practice Address - Fax:559-782-8528
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14613225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT14613Medicare ID - Type Unspecified