Provider Demographics
NPI:1013088558
Name:BACHUS, KELLY LYNN (MED, ATC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYNN
Last Name:BACHUS
Suffix:
Gender:F
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6633 GETTYSBURG DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-4206
Mailing Address - Country:US
Mailing Address - Phone:512-297-0277
Mailing Address - Fax:
Practice Address - Street 1:500 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53706-1314
Practice Address - Country:US
Practice Address - Phone:608-515-3893
Practice Address - Fax:608-265-4736
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11552255A2300X
MSAT03602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer