MEDICARE: KELSEY WHITE IMONDI DPT, PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist	60300414	WA

General Provider Information

NPI Number	:	1275882672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY WHITE IMONDI DPT, PT

Provider Business Mailing Address
First Line	:	9414 NE FOURTH PLAIN ROAD
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98662
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9414 NE FOURTH PLAIN RD
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98662-6109
Country	:	US
Telephone Number	:	360-892-5142
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2012
Last Update Date	:	08/31/2012

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