Provider Demographics
NPI:1376014266
Name:FOUST, KELLY A (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:FOUST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:BROFKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:OCONTO HOSPITAL AND MEDICAL CENTER INC
Practice Address - Street 2:820 ARBUTUS AVE
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153
Practice Address - Country:US
Practice Address - Phone:920-835-1100
Practice Address - Fax:920-835-1099
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14510-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist