Provider Demographics
NPI:1376760520
Name:FAIRFIELD, KELLY ANN (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:FAIRFIELD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 S 188TH AVENUE CIR
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-5642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17021 LAKESIDE HILLS PLZ
Practice Address - Street 2:SUITE 201
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2390
Practice Address - Country:US
Practice Address - Phone:402-758-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2097225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist