Provider Demographics
NPI:1477048387
Name:VASQUEZ, KELLY (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6155 REDBERRY DR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-9778
Mailing Address - Country:US
Mailing Address - Phone:850-496-5685
Mailing Address - Fax:
Practice Address - Street 1:3387 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-3351
Practice Address - Country:US
Practice Address - Phone:850-932-9257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21426225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant