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General NPI Number Information
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NPI Number | 1346428414
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Entity Type | Individual
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Provider Name | KIMI MARIE KELLY OT
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Gender | Female
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Dates
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Enumeration Date | 01/31/2008
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Last Update Date | 10/30/2024
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Provider Practice Location Address
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Address Line | 2661 S BROADWAY
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City | GREEN BAY
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State | WI
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Zip | 54304-5305
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Country | US
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Telephone | 920-592-5262
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Fax |
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Provider Business Mailing Address
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Address Line | 2757 NICOLET DR
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City | GREEN BAY
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State | WI
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Zip | 54311-7219
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Country | US
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Telephone | 920-391-1565
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 838-26
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 383026
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License Number State | WI
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