Provider Demographics
NPI:1043725344
Name:WINGARD, KELLY RENEE
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RENEE
Last Name:WINGARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 WINGARD WOODS LN
Mailing Address - Street 2:
Mailing Address - City:SHIPPENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16254-2241
Mailing Address - Country:US
Mailing Address - Phone:814-316-6360
Mailing Address - Fax:
Practice Address - Street 1:5035 CLAIRTON BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15236-2103
Practice Address - Country:US
Practice Address - Phone:412-440-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP006900224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant