Provider Demographics
NPI:1366831133
Name:RUTHERFORD, KERI
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5942 WILLOWS BRIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-5217
Mailing Address - Country:US
Mailing Address - Phone:386-344-2607
Mailing Address - Fax:
Practice Address - Street 1:5942 WILLOWS BRIDGE LOOP
Practice Address - Street 2:
Practice Address - City:ELLENTON
Practice Address - State:FL
Practice Address - Zip Code:34222-5217
Practice Address - Country:US
Practice Address - Phone:386-344-2607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24573225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant