Provider Demographics
NPI:1609838671
Name:BRUMMER, KELLI JO (MPT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:JO
Last Name:BRUMMER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:JO
Other - Last Name:NOBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:501 ADESSA PKWY STE A140
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37771-6720
Practice Address - Country:US
Practice Address - Phone:865-988-7610
Practice Address - Fax:865-988-6636
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7158225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN446631Medicare ID - Type UnspecifiedGROUP