Provider Demographics
NPI:1114274313
Name:EVANOVICH, KELLY NICOLE (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:EVANOVICH
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 GROVELAND TER
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-1614
Mailing Address - Country:US
Mailing Address - Phone:860-798-0147
Mailing Address - Fax:
Practice Address - Street 1:900 NORTHROP RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1997
Practice Address - Country:US
Practice Address - Phone:203-949-1534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14.0095132251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic