Healthcare Provider Details

I. General information

NPI: 1518212653
Provider Name (Legal Business Name): KYLE WALLING DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 S FERDON BLVD
CRESTVIEW FL
32536-5235
US

IV. Provider business mailing address

5300 S FERDON BLVD
CRESTVIEW FL
32536-5235
US

V. Phone/Fax

Practice location:
  • Phone: 850-398-5756
  • Fax: 850-269-0653
Mailing address:
  • Phone: 850-398-5756
  • Fax: 850-269-0653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT30268
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: