Provider Demographics
NPI:1508162553
Name:ELWELL, KELLI (LPTA)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:ELWELL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-1039
Mailing Address - Country:US
Mailing Address - Phone:575-623-0949
Mailing Address - Fax:
Practice Address - Street 1:3203 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-1039
Practice Address - Country:US
Practice Address - Phone:575-623-0949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-187208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation