Provider Demographics
NPI:1811407430
Name:KELLEY, KELLY LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:WHITNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:41088 BAYOU SEGNETTE AVE
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-8590
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41088 BAYOU SEGNETTE AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-8590
Practice Address - Country:US
Practice Address - Phone:504-330-9373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07099225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL12130928OtherNATIONAL ALLIANCE OF WOUND CARE AND OSTOMY (WCC)
LA07099OtherPT LICENSE