Healthcare Provider Details

I. General information

NPI: 1720625544
Provider Name (Legal Business Name): KELLI KNIPPA LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2019
Last Update Date: 12/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4202 44TH ST
LUBBOCK TX
79413-3304
US

IV. Provider business mailing address

311 RANCHO BUENO DR
GEORGETOWN TX
78628-9520
US

V. Phone/Fax

Practice location:
  • Phone: 512-299-6389
  • Fax:
Mailing address:
  • Phone: 512-299-6389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT7689
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License NumberAT7689
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: