Provider Demographics
NPI:1073307005
Name:BANNERMAN, KELLEY J (PTA)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:J
Last Name:BANNERMAN
Suffix:
Gender:
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:768 HUEY LN
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-7442
Mailing Address - Country:US
Mailing Address - Phone:585-429-0603
Mailing Address - Fax:
Practice Address - Street 1:768 HUEY LN
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-7442
Practice Address - Country:US
Practice Address - Phone:585-429-0603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA29214225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant