Provider Demographics
NPI:1396868568
Name:SANTINE LANDRY, KELLY RAE (MPT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RAE
Last Name:SANTINE LANDRY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4063 GINGER DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-3705
Mailing Address - Country:US
Mailing Address - Phone:228-354-0093
Mailing Address - Fax:228-354-0094
Practice Address - Street 1:4063 GINGER DR
Practice Address - Street 2:SUITE C
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-3705
Practice Address - Country:US
Practice Address - Phone:228-354-0093
Practice Address - Fax:228-354-0094
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2207225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0121391Medicaid
MS650000096Medicare ID - Type UnspecifiedMEDICARE