Provider Demographics
NPI:1023430402
Name:OMMUNDSEN, KELLY (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:OMMUNDSEN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:LANIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:4302 OSAGE DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-3368
Mailing Address - Country:US
Mailing Address - Phone:609-213-3059
Mailing Address - Fax:
Practice Address - Street 1:4302 OSAGE DR
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-3368
Practice Address - Country:US
Practice Address - Phone:609-213-3059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-20
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01472500225100000X
NCP14959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist