Healthcare Provider Details

I. General information

NPI: 1588445688
Provider Name (Legal Business Name): KELLY KRAFFT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 N CENTRAL AVE
KISSIMMEE FL
34741-4407
US

IV. Provider business mailing address

808 DELCHESTER LN
KIRKWOOD MO
63122-1008
US

V. Phone/Fax

Practice location:
  • Phone: 407-870-5959
  • Fax:
Mailing address:
  • Phone: 314-640-3626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2022027290
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number33065
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: