=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861188179
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLI WALKINGTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2023
-----------------------------------------------------
Last Update Date | 04/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1022 E WESLEY DR
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-6107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-744-6613
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 871 CALISTA RIDGE DR
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62221-8303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-781-8260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 160.002655
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------