Provider Demographics
NPI:1912597105
Name:ROBERTSON, KELLYN ASHLEE
Entity Type:Individual
Prefix:
First Name:KELLYN
Middle Name:ASHLEE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13260
Mailing Address - Street 2:
Mailing Address - City:PORT ISABEL
Mailing Address - State:TX
Mailing Address - Zip Code:78578-3260
Mailing Address - Country:US
Mailing Address - Phone:903-521-8286
Mailing Address - Fax:
Practice Address - Street 1:864 CENTRAL BLVD STE 3200
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-8282
Practice Address - Country:US
Practice Address - Phone:956-280-5491
Practice Address - Fax:956-350-9390
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2140990208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty