Provider Demographics
NPI:1942816525
Name:ELY, KELLY ELIZABETH (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:ELY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 N COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-9105
Mailing Address - Country:US
Mailing Address - Phone:630-780-9208
Mailing Address - Fax:
Practice Address - Street 1:785 SE BAYSHORE DR STE 102
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3275
Practice Address - Country:US
Practice Address - Phone:360-279-8323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-19
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61078998225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist