Provider Demographics
NPI:1316213457
Name:BOYER, KELLEY MARIE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:MARIE
Last Name:BOYER
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:PO BOX 1565
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-1565
Mailing Address - Country:US
Mailing Address - Phone:800-642-5031
Mailing Address - Fax:909-989-7633
Practice Address - Street 1:8655 HAVEN AVE STE 200
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4891
Practice Address - Country:US
Practice Address - Phone:800-642-5031
Practice Address - Fax:909-989-7633
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT-4792225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant