Healthcare Provider Details

I. General information

NPI: 1063484889
Provider Name (Legal Business Name): KELLY ANNE FONVILLE MS OTR IL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY ANNE NAPIER MS OTR IL

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 OVERBROOK DR
CONOVER NC
28613-8227
US

IV. Provider business mailing address

3301 OVERBROOK DR
CONOVER NC
28613-8227
US

V. Phone/Fax

Practice location:
  • Phone: 828-256-9488
  • Fax:
Mailing address:
  • Phone: 828-256-9488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5956
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: