Healthcare Provider Details

I. General information

NPI: 1649967456
Provider Name (Legal Business Name): KELLY HANNAH OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 SE WALTON RD
PORT ST LUCIE FL
34952-7657
US

IV. Provider business mailing address

1300 SW NIKOMA ST
PALM CITY FL
34990-2739
US

V. Phone/Fax

Practice location:
  • Phone: 772-337-1333
  • Fax:
Mailing address:
  • Phone: 352-219-2497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number10369
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: