Provider Demographics
NPI:1679098057
Name:WESCOTT, KELLY S (MS, ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:WESCOTT
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 KAIULANI AVE APT 404
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-3003
Mailing Address - Country:US
Mailing Address - Phone:908-619-1453
Mailing Address - Fax:
Practice Address - Street 1:50 S BERETANIA ST STE C117A
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2215
Practice Address - Country:US
Practice Address - Phone:808-544-9360
Practice Address - Fax:808-543-8032
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000005921OtherBOARD OF CERTIFICATION
1034003OtherNATIONAL ATHLETIC TRAINING ASSOCIATION
HI200OtherATHLETIC TRAINER PROGRAM