Healthcare Provider Details

I. General information

NPI: 1538099007
Provider Name (Legal Business Name): MIKAYLA NICOLE KELLEY DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MOE RD
CLIFTON PARK NY
12065-3821
US

IV. Provider business mailing address

32 COACHMAN DR
BALLSTON SPA NY
12020-2710
US

V. Phone/Fax

Practice location:
  • Phone: 518-280-4294
  • Fax:
Mailing address:
  • Phone: 518-225-5031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberP141979
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: