Provider Demographics
NPI:1720105430
Name:NICOLOSI, KELLY MARIE (OTR)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:NICOLOSI
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9670 LAS CASAS DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-8409
Mailing Address - Country:US
Mailing Address - Phone:239-466-0890
Mailing Address - Fax:
Practice Address - Street 1:9670 LAS CASAS DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8409
Practice Address - Country:US
Practice Address - Phone:239-466-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11094225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist