Provider Demographics
NPI:1033660089
Name:COLEMAN, KELLY (MS, ATC)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:MISS
Other - First Name:KELLY ANN
Other - Middle Name:
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, ATC
Mailing Address - Street 1:160 WINDERMERE AVE APT 4603
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-3949
Mailing Address - Country:US
Mailing Address - Phone:203-536-6917
Mailing Address - Fax:
Practice Address - Street 1:160 WINDERMERE AVE APT 4603
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06029-3949
Practice Address - Country:US
Practice Address - Phone:203-536-6917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0007912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer