Provider Demographics
NPI:1457863078
Name:KOCAN, KELSEA RENE (ATC)
Entity Type:Individual
Prefix:MISS
First Name:KELSEA
Middle Name:RENE
Last Name:KOCAN
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 1:6209 SIEBERT ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-2723
Mailing Address - Country:US
Mailing Address - Phone:989-430-0272
Mailing Address - Fax:
Practice Address - Street 1:338 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40506-0001
Practice Address - Country:US
Practice Address - Phone:800-928-2287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-05
Last Update Date:2017-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT13812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer