Provider Demographics
NPI:1932513165
Name:KELLY, JOHN (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 CHERE CAROL RD
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343-3638
Mailing Address - Country:US
Mailing Address - Phone:731-824-5551
Mailing Address - Fax:731-824-5139
Practice Address - Street 1:3525 CHERE CAROL RD
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-3638
Practice Address - Country:US
Practice Address - Phone:731-824-5551
Practice Address - Fax:731-824-5139
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist