Provider Demographics
NPI:1790220093
Name:SYRACUSE, KERRYELLEN LAKIN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KERRYELLEN
Middle Name:LAKIN
Last Name:SYRACUSE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KERRYELLEN
Other - Middle Name:LAKIN
Other - Last Name:WILLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:3820 S JONES BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-2228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-2523
Practice Address - Country:US
Practice Address - Phone:716-505-5630
Practice Address - Fax:716-892-1936
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-23
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037066225100000X
NV3320225100000X
OR61949225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty