Provider Demographics
NPI:1083482293
Name:COPPA, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:COPPA
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 1:208 LEONARD AVE
Mailing Address - Street 2:
Mailing Address - City:WINTERSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43953-4395
Mailing Address - Country:US
Mailing Address - Phone:740-317-6264
Mailing Address - Fax:
Practice Address - Street 1:208 LEONARD AVE
Practice Address - Street 2:
Practice Address - City:WINTERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43953-4395
Practice Address - Country:US
Practice Address - Phone:740-317-6264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI003581225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant