Provider Demographics
NPI:1689296279
Name:ALLEN, KANELA (ATC)
Entity Type:Individual
Prefix:
First Name:KANELA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-4228
Mailing Address - Country:US
Mailing Address - Phone:860-726-3595
Mailing Address - Fax:
Practice Address - Street 1:334 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2675
Practice Address - Country:US
Practice Address - Phone:860-236-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT15042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1504OtherATHLETIC TRAINER LICENSE NUMBER