Provider Demographics
NPI:1992677827
Name:GORDON, KELLY
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:GORDON
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 1:147 STRIKE EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2240
Mailing Address - Country:US
Mailing Address - Phone:931-801-5183
Mailing Address - Fax:
Practice Address - Street 1:151 E REDSTONE AVE
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5352
Practice Address - Country:US
Practice Address - Phone:850-423-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-20
Last Update Date:2025-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA25246225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant