Provider Demographics
NPI:1083045009
Name:BORN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BORN
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 1:2123 N KEENELAND CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-4458
Mailing Address - Country:US
Mailing Address - Phone:316-641-6350
Mailing Address - Fax:
Practice Address - Street 1:402 N HILLCREST AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-4216
Practice Address - Country:US
Practice Address - Phone:316-641-6350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-01
Last Update Date:2013-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-01624225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist