Provider Demographics
NPI:1710221601
Name:LINVILLE, KELLY (ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LINVILLE
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:PO BOX 602
Mailing Address - Street 2:
Mailing Address - City:NORTH CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03860-0602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:568 MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:FRYEBURG
Practice Address - State:ME
Practice Address - Zip Code:04037-1146
Practice Address - Country:US
Practice Address - Phone:207-935-7770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH05402255A2300X
MEAT4502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer