Provider Demographics
NPI:1609922665
Name:MALMQUIST, KELLY J (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:J
Last Name:MALMQUIST
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:ZAHL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:360 MARK COURT
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956
Mailing Address - Country:US
Mailing Address - Phone:920-209-0915
Mailing Address - Fax:
Practice Address - Street 1:1040 PILGRIM WAY
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5028
Practice Address - Country:US
Practice Address - Phone:920-405-3522
Practice Address - Fax:920-405-3523
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1321019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36120300Medicaid