Provider Demographics
NPI:1720257850
Name:MARSHALL, KELLY (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5481 SW 60TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-7698
Mailing Address - Country:US
Mailing Address - Phone:352-873-1122
Mailing Address - Fax:352-873-6841
Practice Address - Street 1:5481 SW 60TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-7698
Practice Address - Country:US
Practice Address - Phone:352-873-1122
Practice Address - Fax:352-873-6841
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21142225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA21142OtherPTA LICENSE NUMBER