Provider Demographics
NPI:1558845529
Name:KELLY, PEYTON ROSE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:PEYTON
Middle Name:ROSE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:ROSIE
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1070 ANGELO CT NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-1042
Mailing Address - Country:US
Mailing Address - Phone:770-315-2305
Mailing Address - Fax:
Practice Address - Street 1:12 EXECUTIVE PARK DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2206
Practice Address - Country:US
Practice Address - Phone:404-778-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0136072251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology