Provider Demographics
NPI:1003811258
Name:CHANDLER, KELLEY NICOLE (PT)
Entity Type:Individual
Prefix:MISS
First Name:KELLEY
Middle Name:NICOLE
Last Name:CHANDLER
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 1:4501 S HARVEST RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-8764
Mailing Address - Country:US
Mailing Address - Phone:573-474-5098
Mailing Address - Fax:
Practice Address - Street 1:1420 W ASHLEY RD
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-2112
Practice Address - Country:US
Practice Address - Phone:660-882-6115
Practice Address - Fax:660-882-6120
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002025550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO122566OtherBCBS
MO484700802Medicaid
MO650025700OtherMEDICARE RAILROAD
MO122566OtherBCBS