Provider Demographics
NPI:1851629547
Name:MARTIN, KELLY CHRISTINE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:CHRISTINE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 640TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHTA
Mailing Address - State:IA
Mailing Address - Zip Code:51061-7024
Mailing Address - Country:US
Mailing Address - Phone:712-213-8674
Mailing Address - Fax:712-743-5013
Practice Address - Street 1:453 640TH ST
Practice Address - Street 2:
Practice Address - City:WASHTA
Practice Address - State:IA
Practice Address - Zip Code:51061-7024
Practice Address - Country:US
Practice Address - Phone:712-213-8674
Practice Address - Fax:712-743-5013
Is Sole Proprietor?:No
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01131225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant