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General NPI Number Information
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NPI Number | 1356630966
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Entity Type | Individual
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Provider Name | KELLY LYN ROE PTA
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Gender | Female
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Dates
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Enumeration Date | 04/04/2011
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Last Update Date | 04/04/2011
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Provider Practice Location Address
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Address Line | 15505 PALMIRA AVE #A
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City | CORPUS CHRISTI
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State | TX
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Zip | 78418-6785
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Country | US
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Telephone | 361-947-4425
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Fax | 361-949-0547
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Provider Business Mailing Address
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Address Line | PO BOX 18801
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City | CORPUS CHRISTI
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State | TX
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Zip | 78480-8801
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Country | US
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Telephone | 361-947-4225
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Fax | 361-949-0547
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2041838
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License Number State | TX
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