Provider Demographics
NPI:1154456028
Name:WILICHOSKI, KELLY JANE (AT,C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:JANE
Last Name:WILICHOSKI
Suffix:
Gender:F
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 PORTSMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:GREENLAND
Mailing Address - State:NH
Mailing Address - Zip Code:03840-2134
Mailing Address - Country:US
Mailing Address - Phone:603-969-3314
Mailing Address - Fax:
Practice Address - Street 1:237 ROUTE 108 STE 101
Practice Address - Street 2:
Practice Address - City:SOMERSWORTH
Practice Address - State:NH
Practice Address - Zip Code:03878-1517
Practice Address - Country:US
Practice Address - Phone:603-749-6686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer