Provider Demographics
NPI:1821229642
Name:WISNER, KELLY JEAN (PT)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:JEAN
Last Name:WISNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:21707 KINGSLAND BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-2518
Mailing Address - Country:US
Mailing Address - Phone:281-398-8235
Mailing Address - Fax:281-398-8246
Practice Address - Street 1:21707 KINGSLAND BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-2518
Practice Address - Country:US
Practice Address - Phone:281-398-8235
Practice Address - Fax:281-398-8246
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1189801225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist