Provider Demographics
NPI:1801377007
Name:SIPPLE, KELLY (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SIPPLE
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 1:24 BIRKDALE DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-2921
Mailing Address - Country:US
Mailing Address - Phone:814-881-7181
Mailing Address - Fax:
Practice Address - Street 1:2551 N GREEN VALLEY PKWY STE 205B
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014
Practice Address - Country:US
Practice Address - Phone:702-476-9759
Practice Address - Fax:702-665-4096
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3790225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist