Provider Demographics
NPI:1508872623
Name:FINE, KELLY RENEE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:FINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40337 ROAD 222
Mailing Address - Street 2:
Mailing Address - City:BASS LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:93604
Mailing Address - Country:US
Mailing Address - Phone:559-658-2864
Mailing Address - Fax:
Practice Address - Street 1:48677 VICTORIA LANE
Practice Address - Street 2:STE 101
Practice Address - City:OAKHURST
Practice Address - State:CA
Practice Address - Zip Code:93644
Practice Address - Country:US
Practice Address - Phone:559-683-4444
Practice Address - Fax:559-683-7053
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT212350Medicare PIN