Healthcare Provider Details

I. General information

NPI: 1508054289
Provider Name (Legal Business Name): SHARON A KELLEY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 COMMANCHE AVE
GREEN BAY WI
54313-6089
US

IV. Provider business mailing address

1630 COMMANCHE AVE
GREEN BAY WI
54313-6089
US

V. Phone/Fax

Practice location:
  • Phone: 920-430-4746
  • Fax:
Mailing address:
  • Phone: 920-430-4746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number575-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: