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General NPI Number Information
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NPI Number | 1750268520
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Entity Type | Individual
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Provider Name | KELLY LYNN WALLACE DPT
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Gender | Female
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Dates
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Enumeration Date | 08/21/2025
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Last Update Date | 08/21/2025
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Provider Practice Location Address
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Address Line | 6169 S JOG RD STE A11
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City | LAKE WORTH
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State | FL
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Zip | 33467-6586
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Country | US
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Telephone | 561-432-0111
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Fax | 561-432-0111
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Provider Business Mailing Address
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Address Line | 780 E DORCHESTER DR
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City | SAINT JOHNS
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State | FL
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Zip | 32259-6287
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Country | US
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Telephone | 386-748-0648
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Fax | 561-432-1075
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT43619
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License Number State | FL
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