Provider Demographics
NPI:1720219306
Name:KOLLANDA, KELLI (LMT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:KOLLANDA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1243 JADE LN NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1105
Mailing Address - Country:US
Mailing Address - Phone:321-794-9119
Mailing Address - Fax:
Practice Address - Street 1:515 N HARBOR CITY BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-6870
Practice Address - Country:US
Practice Address - Phone:321-794-9119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA19848225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist