Provider Demographics
NPI:1023414034
Name:KIRKLAND, KELLY (ATC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KIRKLAND
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2149 W LELAND AVE APT B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-1527
Mailing Address - Country:US
Mailing Address - Phone:989-400-2267
Mailing Address - Fax:
Practice Address - Street 1:2149 W LELAND AVE APT B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-1527
Practice Address - Country:US
Practice Address - Phone:989-400-2267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960028932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer