Healthcare Provider Details

I. General information

NPI: 1992677827
Provider Name (Legal Business Name): MRS. KELLY GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2025
Last Update Date: 09/20/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 E REDSTONE AVE
CRESTVIEW FL
32539-5352
US

IV. Provider business mailing address

147 STRIKE EAGLE DR
CRESTVIEW FL
32536-2240
US

V. Phone/Fax

Practice location:
  • Phone: 850-423-1000
  • Fax:
Mailing address:
  • Phone: 931-801-5183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA25246
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: