Provider Demographics
NPI:1457495749
Name:CANADA, KELLY L (PT)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:L
Last Name:CANADA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
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Mailing Address - Street 1:900 HULL ST S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-2461
Mailing Address - Country:US
Mailing Address - Phone:727-641-3755
Mailing Address - Fax:813-837-3080
Practice Address - Street 1:3416 S DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-8639
Practice Address - Country:US
Practice Address - Phone:813-837-3060
Practice Address - Fax:813-837-3080
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL192172251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic