Healthcare Provider Details

I. General information

NPI: 1558845529
Provider Name (Legal Business Name): PEYTON ROSE KELLY PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROSIE KELLY PT, DPT

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 EXECUTIVE PARK DR NE
ATLANTA GA
30329-2206
US

IV. Provider business mailing address

1070 ANGELO CT NE
ATLANTA GA
30319-1042
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-7777
  • Fax:
Mailing address:
  • Phone: 770-315-2305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License NumberPT013607
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: