Healthcare Provider Details

I. General information

NPI: 1356868814
Provider Name (Legal Business Name): ELIZABETH ANN KELLY PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 08/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8507 NE 8TH WAY
VANCOUVER WA
98664-1980
US

IV. Provider business mailing address

254 D ST APT 4
SALT LAKE CITY UT
84103-2744
US

V. Phone/Fax

Practice location:
  • Phone: 360-254-5335
  • Fax:
Mailing address:
  • Phone: 248-659-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: