Provider Demographics
NPI:1023485141
Name:KEARLEY, CRYSTLE TAIYO (DPT)
Entity type:Individual
Prefix:
First Name:CRYSTLE
Middle Name:TAIYO
Last Name:KEARLEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CRYSTLE
Other - Middle Name:TAIYO
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1675 EAGLE HARBOR PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4802
Mailing Address - Country:US
Mailing Address - Phone:904-637-0148
Mailing Address - Fax:
Practice Address - Street 1:1675 EAGLE HARBOR PKWY
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-4802
Practice Address - Country:US
Practice Address - Phone:904-637-0148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT30362225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist