Provider Demographics
NPI:1003065137
Name:SPANDL, KELLY ANN (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:SPANDL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 S DONNELLY AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55355-2911
Mailing Address - Country:US
Mailing Address - Phone:320-593-4967
Mailing Address - Fax:
Practice Address - Street 1:612 S SIBLEY AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355-3340
Practice Address - Country:US
Practice Address - Phone:320-693-4528
Practice Address - Fax:320-693-4561
Is Sole Proprietor?:No
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA243225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant