Provider Demographics
NPI:1346857521
Name:PETTY, KELLY ANNE (LMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:PETTY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2926 ZUNI ST APT 313
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-3847
Mailing Address - Country:US
Mailing Address - Phone:239-404-5955
Mailing Address - Fax:
Practice Address - Street 1:2926 ZUNI ST APT 313
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-3847
Practice Address - Country:US
Practice Address - Phone:239-404-5955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0022564225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist