Healthcare Provider Details

I. General information

NPI: 1245254523
Provider Name (Legal Business Name): KELLY I HOWARD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MARY AVE SUITE1
NIPOMO CA
93444-7820
US

IV. Provider business mailing address

680 WESTERN
LOVELOCK NV
89419
US

V. Phone/Fax

Practice location:
  • Phone: 805-929-3230
  • Fax: 805-929-3232
Mailing address:
  • Phone: 775-575-5508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT4454
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierAT4454
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerPTA LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: