Provider Demographics
NPI:1760990931
Name:KNAPP, KELLY JEAN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:KNAPP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 ACACIA AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1905
Mailing Address - Country:US
Mailing Address - Phone:415-734-1497
Mailing Address - Fax:
Practice Address - Street 1:740 S PLACENTIA AVE # CA
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-6832
Practice Address - Country:US
Practice Address - Phone:714-646-8318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist