=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922245745
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY LYNN PALMER OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2009
-----------------------------------------------------
Last Update Date | 01/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 134 GRANDVIEW AVE
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06708-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-573-7130
-----------------------------------------------------
Fax | 203-573-7234
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 TOMPKINS ST
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06708-1459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-419-0381
-----------------------------------------------------
Fax | 203-419-0389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 3439
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------