Healthcare Provider Details

I. General information

NPI: 1023517828
Provider Name (Legal Business Name): KATHRYN KELLY ANDERSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45390 GREEN AVE
CALLAHAN FL
32011-3711
US

IV. Provider business mailing address

PO BOX 1609
CALLAHAN FL
32011-1609
US

V. Phone/Fax

Practice location:
  • Phone: 904-879-1223
  • Fax: 904-879-4986
Mailing address:
  • Phone: 904-879-1223
  • Fax: 904-979-4986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPTA24543
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: