Provider Demographics
NPI:1629296769
Name:MIDDENDORF, KELLY ERIN (DI)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ERIN
Last Name:MIDDENDORF
Suffix:
Gender:F
Credentials:DI
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3067 MAGNOLIA CT
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3371
Mailing Address - Country:US
Mailing Address - Phone:859-341-4077
Mailing Address - Fax:859-341-0573
Practice Address - Street 1:3067 MAGNOLIA CT
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3371
Practice Address - Country:US
Practice Address - Phone:859-341-4077
Practice Address - Fax:859-341-0573
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY222Q00000X2251C2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251C2600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistCardiopulmonary