Provider Demographics
NPI:1295336360
Name:WALTON, KELLY LYNN (PT)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:LYNN
Last Name:WALTON
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 1:87 N MARGARET DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE MARBLEHEAD
Mailing Address - State:OH
Mailing Address - Zip Code:43440-2514
Mailing Address - Country:US
Mailing Address - Phone:419-217-5272
Mailing Address - Fax:
Practice Address - Street 1:9400 N SHORE BLVD
Practice Address - Street 2:
Practice Address - City:LAKESIDE MARBLEHEAD
Practice Address - State:OH
Practice Address - Zip Code:43440-1337
Practice Address - Country:US
Practice Address - Phone:419-798-8203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH-10555225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist