Provider Demographics
NPI:1013482132
Name:CONNERY, KELLIE LINN (PT)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:LINN
Last Name:CONNERY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:LINN
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:530 BOGACHIEL WAY
Mailing Address - Street 2:
Mailing Address - City:FORKS
Mailing Address - State:WA
Mailing Address - Zip Code:98331
Mailing Address - Country:US
Mailing Address - Phone:360-374-6271
Mailing Address - Fax:360-374-2520
Practice Address - Street 1:530 BOGACHIEL WAY
Practice Address - Street 2:
Practice Address - City:FORKS
Practice Address - State:WA
Practice Address - Zip Code:98331
Practice Address - Country:US
Practice Address - Phone:360-374-6271
Practice Address - Fax:360-374-2520
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62705225100000X
WAPT60914300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist