Provider Demographics
NPI:1578728036
Name:SHAMP, KELLY F (LMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:F
Last Name:SHAMP
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 WINTON PL
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-2805
Mailing Address - Country:US
Mailing Address - Phone:585-794-0168
Mailing Address - Fax:
Practice Address - Street 1:3450 WINTON PL
Practice Address - Street 2:SUITE 4
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2805
Practice Address - Country:US
Practice Address - Phone:585-794-0168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019562-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist