Provider Demographics
NPI:1578773065
Name:SARVIS, KERRY LEE (MS, ATC, CSCS, FMSC)
Entity Type:Individual
Prefix:MRS
First Name:KERRY
Middle Name:LEE
Last Name:SARVIS
Suffix:
Gender:F
Credentials:MS, ATC, CSCS, FMSC
Other - Prefix:MISS
Other - First Name:KERRY
Other - Middle Name:LEE
Other - Last Name:WINGARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:120 WARREN CT
Mailing Address - Street 2:
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459-3108
Mailing Address - Country:US
Mailing Address - Phone:580-574-6854
Mailing Address - Fax:
Practice Address - Street 1:120 WARREN CT
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-3108
Practice Address - Country:US
Practice Address - Phone:580-574-6854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0021812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer