Provider Demographics
NPI:1477700714
Name:WELLS, KAREN KAY (PT)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:KAY
Last Name:WELLS
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 1:719 S ROGERS ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2332
Mailing Address - Country:US
Mailing Address - Phone:812-323-4475
Mailing Address - Fax:812-323-4478
Practice Address - Street 1:719 S ROGERS ST
Practice Address - Street 2:SUITE B
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2332
Practice Address - Country:US
Practice Address - Phone:812-323-4475
Practice Address - Fax:812-323-4478
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003173A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200908750Medicaid
IN549210OOOOMedicare PIN