Provider Demographics
NPI:1790874501
Name:WILKINS, KELLY L (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:WILKINS
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 1:97 SHERMAN DR
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9280
Mailing Address - Country:US
Mailing Address - Phone:802-748-3722
Mailing Address - Fax:802-748-1593
Practice Address - Street 1:97 SHERMAN DR
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9280
Practice Address - Country:US
Practice Address - Phone:802-748-3722
Practice Address - Fax:802-748-1593
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0003579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT68624OtherBLUE CROSS BLUE SHIELD VT