Provider Demographics
NPI:1245994821
Name:TIBBETTS, KYLEE LYNN (PTA)
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:LYNN
Last Name:TIBBETTS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8539 GATE PKWY W UNIT 1527
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1046
Mailing Address - Country:US
Mailing Address - Phone:904-487-4738
Mailing Address - Fax:
Practice Address - Street 1:8700 A C SKINNER PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0836
Practice Address - Country:US
Practice Address - Phone:904-642-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA31541225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant