Provider Demographics
NPI:1679818793
Name:HOLMES, KILEY ZELLITTI (DPT)
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:ZELLITTI
Last Name:HOLMES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KILEY
Other - Middle Name:ROSE
Other - Last Name:ZELLITTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:645 E STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5915
Mailing Address - Country:US
Mailing Address - Phone:208-939-9594
Mailing Address - Fax:208-939-9828
Practice Address - Street 1:904 S VANGUARD WAY STE 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7552
Practice Address - Country:US
Practice Address - Phone:208-803-6767
Practice Address - Fax:208-803-6766
Is Sole Proprietor?:No
Enumeration Date:2012-11-29
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25568225100000X
WAPT60363672225100000X
IDPT-6736225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0312053OtherDEPT OF LABOR AND INDUSTRIES
WAG8923078Medicare PIN
WAG8923077Medicare PIN