Healthcare Provider Details

I. General information

NPI: 1306010913
Provider Name (Legal Business Name): KRISTIN NICOLE KELLIM M.P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN NICOLE WALLACE PT MPT

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E COLORADO ST STE 120
GLENDALE CA
91205-1651
US

IV. Provider business mailing address

3200 BRISTOL ST STE 600
COSTA MESA CA
92626-1810
US

V. Phone/Fax

Practice location:
  • Phone: 213-212-4308
  • Fax: 213-261-0973
Mailing address:
  • Phone: 213-212-4308
  • Fax: 213-261-0973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number2008010372
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.017045
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40993
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: