Provider Demographics
NPI:1356630966
Name:ROE, KELLY LYN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYN
Last Name:ROE
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:PO BOX 18801
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78480-8801
Mailing Address - Country:US
Mailing Address - Phone:361-947-4225
Mailing Address - Fax:361-949-0547
Practice Address - Street 1:15505 PALMIRA AVE
Practice Address - Street 2:#A
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78418-6785
Practice Address - Country:US
Practice Address - Phone:361-947-4425
Practice Address - Fax:361-949-0547
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2041838225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant