Provider Demographics
NPI:1518679810
Name:REYNOLDS, KELLY MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:REYNOLDS
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 1:3200 WHITEHORSE CT
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-1285
Mailing Address - Country:US
Mailing Address - Phone:912-257-2480
Mailing Address - Fax:
Practice Address - Street 1:1851 ELKCAM BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-3922
Practice Address - Country:US
Practice Address - Phone:386-789-3769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28017208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation