Healthcare Provider Details

I. General information

NPI: 1275882672
Provider Name (Legal Business Name): KELSEY WHITE IMONDI DPT, PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELSEY JEAN WHITE

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9414 NE FOURTH PLAIN RD
VANCOUVER WA
98662-6109
US

IV. Provider business mailing address

9414 NE FOURTH PLAIN ROAD
VANCOUVER WA
98662
US

V. Phone/Fax

Practice location:
  • Phone: 360-892-5142
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number60300414
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: