Provider Demographics
NPI:1417347097
Name:KELLY, REGINA Y (PT)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:Y
Last Name:KELLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6421 BORASCO DR
Mailing Address - Street 2:#2206
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6138
Mailing Address - Country:US
Mailing Address - Phone:321-945-1200
Mailing Address - Fax:
Practice Address - Street 1:2316 S FISKE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3427
Practice Address - Country:US
Practice Address - Phone:321-632-0081
Practice Address - Fax:321-632-0993
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT16819225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist