Healthcare Provider Details

I. General information

NPI: 1902445489
Provider Name (Legal Business Name): KELSEY COOLIDGE BOARDMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3831 PIPER ST STE S-320
ANCHORAGE AK
99508-4680
US

IV. Provider business mailing address

3627 WILLIAMS ST
ANCHORAGE AK
99508-4535
US

V. Phone/Fax

Practice location:
  • Phone: 907-563-3145
  • Fax:
Mailing address:
  • Phone: 907-952-3612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: