Healthcare Provider Details

I. General information

NPI: 1396298832
Provider Name (Legal Business Name): KELLY DAVIS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 VANDALIA ST SUITE 105
SAINT PAUL MN
55114-1833
US

IV. Provider business mailing address

7551 9TH ST N SUITE 100
OAKDALE MN
55128-6629
US

V. Phone/Fax

Practice location:
  • Phone: 651-348-7428
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10346
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: