Provider Demographics
NPI:1891883898
Name:FRUSTACI, KELLY K (PT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:K
Last Name:FRUSTACI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 KINGSLEY AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5180
Mailing Address - Country:US
Mailing Address - Phone:904-272-2830
Mailing Address - Fax:904-272-8814
Practice Address - Street 1:2140 KINGSLEY AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5180
Practice Address - Country:US
Practice Address - Phone:904-272-2830
Practice Address - Fax:904-272-8814
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10854225100000X
FLPT 23876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist