Provider Demographics
NPI:1053419929
Name:BURDETTE, KELLY ANNE (LPTA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:BURDETTE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 TIPTON DR
Mailing Address - Street 2:
Mailing Address - City:TUSCUMBIA
Mailing Address - State:AL
Mailing Address - Zip Code:35674-3120
Mailing Address - Country:US
Mailing Address - Phone:256-381-8408
Mailing Address - Fax:
Practice Address - Street 1:300 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:AL
Practice Address - Zip Code:35650-1268
Practice Address - Country:US
Practice Address - Phone:256-974-1146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL660225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant