Provider Demographics
NPI:1194195826
Name:KELLY, MELANI (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MELANI
Middle Name:
Last Name:KELLY
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 1:702 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-2607
Mailing Address - Country:US
Mailing Address - Phone:360-623-5259
Mailing Address - Fax:
Practice Address - Street 1:702 3RD AVENUE
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015
Practice Address - Country:US
Practice Address - Phone:360-623-5259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT57352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer