Provider Demographics
NPI:1528125499
Name:POWERS, KELLY ANN (PT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:POWERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 WALLACE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-9169
Mailing Address - Country:US
Mailing Address - Phone:850-304-3874
Mailing Address - Fax:
Practice Address - Street 1:2775 WALLACE LAKE RD
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-9169
Practice Address - Country:US
Practice Address - Phone:850-304-3874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 27028225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist