Healthcare Provider Details

I. General information

NPI: 1003065137
Provider Name (Legal Business Name): KELLY ANN SPANDL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 09/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 S SIBLEY AVE
LITCHFIELD MN
55355-3340
US

IV. Provider business mailing address

519 S DONNELLY AVE
LITCHFIELD MN
55355-2911
US

V. Phone/Fax

Practice location:
  • Phone: 320-693-4528
  • Fax: 320-693-4561
Mailing address:
  • Phone: 320-593-4967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA243
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: