Provider Demographics
NPI:1063466969
Name:STOLEY-ROESNER, KELLY SUE (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:STOLEY-ROESNER
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 1:8522 OAKBROOK RDG NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9375
Mailing Address - Country:US
Mailing Address - Phone:616-866-6103
Mailing Address - Fax:
Practice Address - Street 1:570 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1323
Practice Address - Country:US
Practice Address - Phone:616-866-0141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004056225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist