Provider Demographics
NPI:1710371562
Name:TINDALL, KELLY JO (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:TINDALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64724-1346
Mailing Address - Country:US
Mailing Address - Phone:660-492-0671
Mailing Address - Fax:
Practice Address - Street 1:313 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:APPLETON CITY
Practice Address - State:MO
Practice Address - Zip Code:64724-1346
Practice Address - Country:US
Practice Address - Phone:660-492-0671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008021949225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist