Provider Demographics
NPI:1255526497
Name:KELLY, BRENDA CHARLENE (PT)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:CHARLENE
Last Name:KELLY
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 1:3599 UNIVERSITY BLVD S
Mailing Address - Street 2:JACKSONVILLE
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4252
Mailing Address - Country:US
Mailing Address - Phone:904-858-7600
Mailing Address - Fax:904-399-6690
Practice Address - Street 1:3599 UNIVERSITY BLVD S
Practice Address - Street 2:JACKSONVILLE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4252
Practice Address - Country:US
Practice Address - Phone:904-858-7600
Practice Address - Fax:904-399-6690
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0001225225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist