Provider Demographics
NPI:1225723943
Name:LOUDON, KELLY (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LOUDON
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 SCHWAGER DRIVE
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190
Mailing Address - Country:US
Mailing Address - Phone:262-949-9408
Mailing Address - Fax:
Practice Address - Street 1:907 SCHWAGER DRIVE
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-9452
Practice Address - Country:US
Practice Address - Phone:262-949-9408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer