Provider Demographics
NPI:1689902900
Name:WITCHLEY, KELLY ANN (LMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:WITCHLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7004 YAGER RD
Mailing Address - Street 2:
Mailing Address - City:DURHAMVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13054-3151
Mailing Address - Country:US
Mailing Address - Phone:315-368-4574
Mailing Address - Fax:
Practice Address - Street 1:202 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-6541
Practice Address - Country:US
Practice Address - Phone:315-368-4574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022736172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist