Provider Demographics
NPI:1407102585
Name:CARPENTER, KELLY
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:DUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2002 W SUNSET DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-2283
Mailing Address - Country:US
Mailing Address - Phone:307-856-7021
Mailing Address - Fax:307-856-5546
Practice Address - Street 1:2002 W SUNSET DR
Practice Address - Street 2:SUITE 1
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2283
Practice Address - Country:US
Practice Address - Phone:307-856-7021
Practice Address - Fax:307-856-5546
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPTA-0756225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant