Provider Demographics
NPI:1669850715
Name:IBE, KELLY (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:IBE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:PETTISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13333 GREENWOOD AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-7312
Mailing Address - Country:US
Mailing Address - Phone:206-446-8294
Mailing Address - Fax:
Practice Address - Street 1:13333 GREENWOOD AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-7312
Practice Address - Country:US
Practice Address - Phone:206-446-8294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-09
Last Update Date:2015-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160500252225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant