Provider Demographics
NPI:1093910812
Name:WEIDINGER, KELLEY LUCILLE (ATC, LAT)
Entity Type:Individual
Prefix:MISS
First Name:KELLEY
Middle Name:LUCILLE
Last Name:WEIDINGER
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11820 MARIES ROAD 328
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:MO
Mailing Address - Zip Code:65582-7123
Mailing Address - Country:US
Mailing Address - Phone:573-680-3826
Mailing Address - Fax:
Practice Address - Street 1:3308 W EDGEWOOD DR STE F
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6891
Practice Address - Country:US
Practice Address - Phone:573-638-3400
Practice Address - Fax:573-638-3405
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070172522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer