Provider Demographics
NPI:1659719805
Name:MOSIMANN, KELLEY MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:MARIE
Last Name:MOSIMANN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35257 HIGHWAY 87
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-4448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-2002
Practice Address - Country:US
Practice Address - Phone:575-445-0111
Practice Address - Fax:575-445-0112
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8602588-2401225100000X
NM4316225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist