Provider Demographics
NPI:1205814142
Name:KELLER, KIERNAN JOAN (PT)
Entity Type:Individual
Prefix:
First Name:KIERNAN
Middle Name:JOAN
Last Name:KELLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIERNAN
Other - Middle Name:JOAN
Other - Last Name:DOELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:14811 77TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98296-8438
Mailing Address - Country:US
Mailing Address - Phone:360-668-5910
Mailing Address - Fax:360-668-5910
Practice Address - Street 1:14811 77TH AVE SE
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98296-8438
Practice Address - Country:US
Practice Address - Phone:360-668-5910
Practice Address - Fax:360-668-5910
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist