Provider Demographics
NPI:1790235026
Name:MILLS, KELLY JEAN (DPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEAN
Last Name:MILLS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:NOONAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 1ST AVE E
Mailing Address - Street 2:STE C
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-4342
Mailing Address - Country:US
Mailing Address - Phone:712-262-7511
Mailing Address - Fax:712-262-3658
Practice Address - Street 1:1200 1ST AVE E
Practice Address - Street 2:STE C
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4342
Practice Address - Country:US
Practice Address - Phone:712-262-7511
Practice Address - Fax:712-262-3658
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA073975225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist