Provider Demographics
NPI:1083184154
Name:KOENIG, KELLY ANN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:KOENIG
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 1:1376 BREAM AVE
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-8456
Mailing Address - Country:US
Mailing Address - Phone:803-460-1521
Mailing Address - Fax:
Practice Address - Street 1:1376 BREAM AVE
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-8456
Practice Address - Country:US
Practice Address - Phone:803-460-1521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer