MEDICARE: KELLY LYNN WALLACE DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT43619	FL
2	225100000X	Physical Therapist	1407872	TX
3	225100000X	Physical Therapist	310150	CA

General Provider Information

NPI Number	:	1750268520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LYNN WALLACE DPT

Provider Business Mailing Address
First Line	:	780 E DORCHESTER DR
Second Line	:
City	:	SAINT JOHNS
State	:	FL
Zip	:	32259-6287
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6801 PARK TER STE 200
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-1546
Country	:	US
Telephone Number	:	310-665-7100
Fax Number	:	310-665-7101

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2025
Last Update Date	:	05/26/2026

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Directions to “ KELLY LYNN WALLACE DPT” Practice Location

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