Provider Demographics
NPI:1407170798
Name:DESPLINTER, KELLI RAE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:RAE
Last Name:DESPLINTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16142 E 2600TH ST
Mailing Address - Street 2:
Mailing Address - City:ANNAWAN
Mailing Address - State:IL
Mailing Address - Zip Code:61234-9533
Mailing Address - Country:US
Mailing Address - Phone:309-540-9278
Mailing Address - Fax:
Practice Address - Street 1:16142 E 2600 ST
Practice Address - Street 2:
Practice Address - City:ANNAWAN
Practice Address - State:IL
Practice Address - Zip Code:61234
Practice Address - Country:US
Practice Address - Phone:309-540-9278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004749225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant