Provider Demographics
NPI:1598963167
Name:CUNNINGHAM, KELLY (PTA)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 PINEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-6703
Mailing Address - Country:US
Mailing Address - Phone:740-373-3597
Mailing Address - Fax:
Practice Address - Street 1:400 N 7TH ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-2024
Practice Address - Country:US
Practice Address - Phone:740-373-3597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0601586225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant