Provider Demographics
NPI:1851115539
Name:RUDOLPH, KELLI (OTA)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N PACE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-7915
Mailing Address - Country:US
Mailing Address - Phone:406-253-9498
Mailing Address - Fax:850-782-0058
Practice Address - Street 1:1810 W CERVANTES ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-0001
Practice Address - Country:US
Practice Address - Phone:406-253-9498
Practice Address - Fax:850-782-0058
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11576224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant