Provider Demographics
NPI:1730389420
Name:BURGENSTOCK, KELLY MCNABB
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MCNABB
Last Name:BURGENSTOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 JOINER STREET
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4204
Mailing Address - Country:US
Mailing Address - Phone:321-945-7030
Mailing Address - Fax:
Practice Address - Street 1:1816 PRAIRIE LAKE BLVD
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761
Practice Address - Country:US
Practice Address - Phone:321-945-7030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27030225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist