Provider Demographics
NPI:1326011651
Name:LEGACY, KELLY BROMLEY (DPT)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:BROMLEY
Last Name:LEGACY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:BROMLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:9 RESERVOIR HTS
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-3437
Mailing Address - Country:US
Mailing Address - Phone:603-536-2567
Mailing Address - Fax:
Practice Address - Street 1:15 TOWN WEST RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-3428
Practice Address - Country:US
Practice Address - Phone:603-536-2941
Practice Address - Fax:603-536-2949
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2836225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30392279Medicaid
NH30138YMedicare UPIN
NHRE7176Medicare PIN