Provider Demographics
NPI:1548818065
Name:WHITLEY, KELLY MARIE (PT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:VANLANDINGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2740 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6141
Mailing Address - Country:US
Mailing Address - Phone:501-329-5459
Mailing Address - Fax:
Practice Address - Street 1:2474 E JOYCE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4932
Practice Address - Country:US
Practice Address - Phone:479-521-8326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4732225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist