1972817773 NPI number — DR. KELLY LAURAINE BLAKE FRANCES PT, DPT

Table of content: DR. KELLY LAURAINE BLAKE FRANCES PT, DPT (NPI 1972817773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972817773 NPI number — DR. KELLY LAURAINE BLAKE FRANCES PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKE FRANCES
Provider First Name:
KELLY
Provider Middle Name:
LAURAINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972817773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7654 N NOB HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMARAC
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33321-1869
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-597-6666
Provider Business Mailing Address Fax Number:
954-597-6677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7654 N NOB HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMARAC
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-597-6666
Provider Business Practice Location Address Fax Number:
954-597-6677
Provider Enumeration Date:
08/04/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  25734 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)