Provider Demographics
NPI:1427522747
Name:KELLY, CHASE MARTIN
Entity type:Individual
Prefix:
First Name:CHASE
Middle Name:MARTIN
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 OLD LOGGERS WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4316
Mailing Address - Country:US
Mailing Address - Phone:904-540-4663
Mailing Address - Fax:
Practice Address - Street 1:1390 SAND HILL RD
Practice Address - Street 2:
Practice Address - City:CANDLER
Practice Address - State:NC
Practice Address - Zip Code:28715-8938
Practice Address - Country:US
Practice Address - Phone:828-670-7726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-21
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
NCP22521225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer