Provider Demographics
NPI:1003620188
Name:WIMMER, KELSIE LENNA (PTA)
Entity type:Individual
Prefix:
First Name:KELSIE
Middle Name:LENNA
Last Name:WIMMER
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 1:10165 N 6960 W
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-9223
Mailing Address - Country:US
Mailing Address - Phone:801-425-5268
Mailing Address - Fax:
Practice Address - Street 1:4587 W CEDAR HILLS DR STE 110
Practice Address - Street 2:
Practice Address - City:CEDAR HILLS
Practice Address - State:UT
Practice Address - Zip Code:84062-8827
Practice Address - Country:US
Practice Address - Phone:801-406-6943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14202060-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant