Provider Demographics
NPI:1922273465
Name:KELLY, JANELLE LEANN (PT)
Entity Type:Individual
Prefix:
First Name:JANELLE
Middle Name:LEANN
Last Name:KELLY
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 1:104 PARK TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:MACKINAW
Mailing Address - State:IL
Mailing Address - Zip Code:61755-7514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6501 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2932
Practice Address - Country:US
Practice Address - Phone:309-692-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.011618225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist