Provider Demographics
NPI:1386634137
Name:LUNA, KELLY J (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:LUNA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:J
Other - Last Name:VANDENBOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:LAJES FIELD 65 MDG
Mailing Address - Street 2:UNIT 7745
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09720-7745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 76 BOX 7745
Practice Address - Street 2:LAJES FIELD 65 MDG
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09720-7745
Practice Address - Country:US
Practice Address - Phone:351-535-1118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009867225100000X
PAPT018699225100000X
NC11392225100000X
FLPT28147225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist