Provider Demographics
NPI:1588617252
Name:CLYMER, KELLY NICOLE (PT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:NICOLE
Last Name:CLYMER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-0950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2416
Practice Address - Country:US
Practice Address - Phone:415-457-4454
Practice Address - Fax:415-457-4944
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19225225100000X
VA2305203787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist