Provider Demographics
NPI:1851500227
Name:NORMAN, KELLY MICHELLE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MICHELLE
Last Name:NORMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:MICHELLE
Other - Last Name:KIENITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1357 PONDEROSA AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-5944
Mailing Address - Country:US
Mailing Address - Phone:920-569-6349
Mailing Address - Fax:
Practice Address - Street 1:1375 S CARRINGTON LN
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-4227
Practice Address - Country:US
Practice Address - Phone:920-227-7210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI528-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40478800Medicaid