Provider Demographics
NPI:1679167605
Name:THURMOND, KELLY (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:THURMOND
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 1:325 BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-1550
Mailing Address - Country:US
Mailing Address - Phone:443-974-0012
Mailing Address - Fax:
Practice Address - Street 1:4000 RIVER CRESCENT DR
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7721
Practice Address - Country:US
Practice Address - Phone:410-266-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-20
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA5458225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant