Provider Demographics
NPI:1376153627
Name:FISKE, KELLE (ATC)
Entity Type:Individual
Prefix:
First Name:KELLE
Middle Name:
Last Name:FISKE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12242 SCARLET WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2649
Mailing Address - Country:US
Mailing Address - Phone:909-659-3898
Mailing Address - Fax:
Practice Address - Street 1:12242 SCARLET WAY
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-2649
Practice Address - Country:US
Practice Address - Phone:909-659-3898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-02
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer