Provider Demographics
NPI:1750673646
Name:KELLY, MENDI L (PTA)
Entity Type:Individual
Prefix:
First Name:MENDI
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MENDI
Other - Middle Name:L
Other - Last Name:HEUERTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:3421 SHEFFIELD ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68112-2328
Mailing Address - Country:US
Mailing Address - Phone:402-557-6067
Mailing Address - Fax:402-934-3686
Practice Address - Street 1:1103 GALVIN RD S
Practice Address - Street 2:AREA A
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3004
Practice Address - Country:US
Practice Address - Phone:402-557-6067
Practice Address - Fax:402-934-3686
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE429225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant