Provider Demographics
NPI:1407890858
Name:LIGHT, KELLEY HINSON (PT)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:HINSON
Last Name:LIGHT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6169 S JOG RD
Mailing Address - Street 2:SUITE A11
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-6579
Mailing Address - Country:US
Mailing Address - Phone:561-432-0111
Mailing Address - Fax:561-432-1075
Practice Address - Street 1:5601 OKEECHOBEE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33417-4489
Practice Address - Country:US
Practice Address - Phone:561-432-0111
Practice Address - Fax:561-432-1075
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2017-04-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FL16176225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7222VMedicare PIN