Provider Demographics
NPI:1730662107
Name:HAMMA, KELLI THOMPSON
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:THOMPSON
Last Name:HAMMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:DENISE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CMT
Mailing Address - Street 1:630 LANCASTER DR
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420
Mailing Address - Country:US
Mailing Address - Phone:805-704-2723
Mailing Address - Fax:
Practice Address - Street 1:630 LANCASTER DR
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420
Practice Address - Country:US
Practice Address - Phone:805-704-2723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46726225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA46726OtherCMT LICENSE