Provider Demographics
NPI:1225273345
Name:MIKKELSON, KERRY LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:LYNN
Last Name:MIKKELSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5124 MIDDLE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-5334
Mailing Address - Country:US
Mailing Address - Phone:406-256-7999
Mailing Address - Fax:
Practice Address - Street 1:1233 N 30TH ST
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-0127
Practice Address - Country:US
Practice Address - Phone:406-256-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1120225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant