Provider Demographics
NPI:1003398546
Name:FACTEAU, KELLY ANN (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:FACTEAU
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7619
Mailing Address - Street 2:
Mailing Address - City:SIASCONSET
Mailing Address - State:MA
Mailing Address - Zip Code:02564-7619
Mailing Address - Country:US
Mailing Address - Phone:508-642-0003
Mailing Address - Fax:
Practice Address - Street 1:6 BAYBERRY CT
Practice Address - Street 2:
Practice Address - City:NANTUCKET
Practice Address - State:MA
Practice Address - Zip Code:02554-4039
Practice Address - Country:US
Practice Address - Phone:508-825-8191
Practice Address - Fax:508-825-8198
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI01215225100000X
NH4343225100000X
MA11004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist