Provider Demographics
NPI:1750268520
Name:WALLACE, KELLY LYNN (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:780 E DORCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-6287
Mailing Address - Country:US
Mailing Address - Phone:386-748-0648
Mailing Address - Fax:561-432-1075
Practice Address - Street 1:6169 S JOG RD STE A11
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-6586
Practice Address - Country:US
Practice Address - Phone:561-432-0111
Practice Address - Fax:561-432-0111
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPT43619225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist