Provider Demographics
NPI:1588602874
Name:VREDEVELD, KELLY GERRIT (PT)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:GERRIT
Last Name:VREDEVELD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7636 E NIGHTINGALE STAR LN
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-3049
Mailing Address - Country:US
Mailing Address - Phone:928-710-8486
Mailing Address - Fax:928-772-9340
Practice Address - Street 1:2852 N NAVAJO DR
Practice Address - Street 2:SUITE A
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314
Practice Address - Country:US
Practice Address - Phone:928-710-8486
Practice Address - Fax:928-772-9340
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ5810225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist