Provider Demographics
NPI:1093157307
Name:LUSE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LUSE
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 1:5013 HOLYOKE WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-3022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5013 HOLYOKE WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-3022
Practice Address - Country:US
Practice Address - Phone:916-283-5013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-28
Last Update Date:2013-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer