Provider Demographics
NPI:1467930008
Name:COLVIN, KAYLEY O'CONNOR
Entity Type:Individual
Prefix:
First Name:KAYLEY
Middle Name:O'CONNOR
Last Name:COLVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80867
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46898-0867
Mailing Address - Country:US
Mailing Address - Phone:260-338-1241
Mailing Address - Fax:
Practice Address - Street 1:4935 HILLEGAS RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-1934
Practice Address - Country:US
Practice Address - Phone:262-033-8124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013041A2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics