Provider Demographics
NPI:1952724395
Name:WALLIS, KELLY (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6309 CORPORATE CT
Mailing Address - Street 2:STE. 110
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3538
Mailing Address - Country:US
Mailing Address - Phone:239-433-1011
Mailing Address - Fax:239-433-3737
Practice Address - Street 1:6309 CORPORATE CT
Practice Address - Street 2:STE. 110
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3538
Practice Address - Country:US
Practice Address - Phone:239-433-1011
Practice Address - Fax:239-433-3737
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10990111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor