Provider Demographics
NPI:1841682440
Name:LAYTON, KELLI
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:LAYTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:394 TWIN LAKES DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-8368
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:803 OAK ST
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-4317
Practice Address - Country:US
Practice Address - Phone:904-284-5606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 25335225200000X
GAPTA003319225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant