Provider Demographics
NPI:1396418273
Name:KELLY, KRISTEN L (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:L
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 1:9835 CHUMUCKLA SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:FL
Mailing Address - Zip Code:32565-9385
Mailing Address - Country:US
Mailing Address - Phone:850-454-5349
Mailing Address - Fax:
Practice Address - Street 1:6982 PINE FOREST RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526-8909
Practice Address - Country:US
Practice Address - Phone:850-750-5203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28844208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation