Provider Demographics
NPI:1962630244
Name:WAY, KELLIE NICOLE (MS, ATC, LAT, CSCS)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:NICOLE
Last Name:WAY
Suffix:
Gender:F
Credentials:MS, ATC, LAT, CSCS
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:NICOLE
Other - Last Name:COX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, ATC, LAT
Mailing Address - Street 1:1378 MEADOW LARK DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7164
Mailing Address - Country:US
Mailing Address - Phone:321-298-8247
Mailing Address - Fax:
Practice Address - Street 1:3401 TECHNOLOGICAL AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817
Practice Address - Country:US
Practice Address - Phone:407-681-2520
Practice Address - Fax:407-649-1414
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 23012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer