Provider Demographics
NPI:1114430253
Name:KELLY, KRISTINA MARIE (DPT)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 HITT ST RM 3132
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65211-2104
Mailing Address - Country:US
Mailing Address - Phone:573-884-2924
Mailing Address - Fax:614-293-6111
Practice Address - Street 1:1030 HITT ST RM 3132
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65211-2104
Practice Address - Country:US
Practice Address - Phone:573-884-2924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-12
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT015543225100000X
MO2251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0339774Medicaid