Provider Demographics
NPI:1366856924
Name:KELLY, LEVELLA (PTA)
Entity Type:Individual
Prefix:
First Name:LEVELLA
Middle Name:
Last Name:KELLY
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 1:3856 NOBLE ST
Mailing Address - Street 2:APT 811
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-4954
Mailing Address - Country:US
Mailing Address - Phone:601-473-4992
Mailing Address - Fax:
Practice Address - Street 1:3856 NOBLE ST
Practice Address - Street 2:APT 811
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-4954
Practice Address - Country:US
Practice Address - Phone:601-473-4992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA4733225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant