Provider Demographics
NPI:1588445688
Name:KRAFFT, KELLY (PTA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KRAFFT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 DELCHESTER LN
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-1008
Mailing Address - Country:US
Mailing Address - Phone:314-640-3626
Mailing Address - Fax:
Practice Address - Street 1:1207 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4407
Practice Address - Country:US
Practice Address - Phone:407-870-5959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022027290225200000X
FL33065225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant