Provider Demographics
NPI:1164201059
Name:KENNEDY, KELLI (PT, DPT)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 BRADEN AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-2001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:834 PINEBROOK RD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-7123
Practice Address - Country:US
Practice Address - Phone:941-484-8107
Practice Address - Fax:941-484-5186
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305216701225100000X
FLPT40483225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist