Provider Demographics
NPI:1437427861
Name:WALKER, KELLY LYNN (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:WALKER
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 CEDAR ROAD
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754
Mailing Address - Country:US
Mailing Address - Phone:631-487-2149
Mailing Address - Fax:
Practice Address - Street 1:48 CEDAR RD
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-3307
Practice Address - Country:US
Practice Address - Phone:631-487-2149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27 020636172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist