Provider Demographics
NPI:1265109391
Name:PALMER, KENNETH SCOTT (PT, DPT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:SCOTT
Last Name:PALMER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12638 IRIS LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-4850
Mailing Address - Country:US
Mailing Address - Phone:239-850-3039
Mailing Address - Fax:
Practice Address - Street 1:9975 TAVISTOCK LAKES BLVD STE 140
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7665
Practice Address - Country:US
Practice Address - Phone:407-930-7803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT30455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist