Provider Demographics
NPI:1023502739
Name:PENN, KELLY ANNE (PT, DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:PENN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANNE
Other - Last Name:FREATHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:23683 HARVARD SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15959 HALL RD STE 410
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-5365
Practice Address - Country:US
Practice Address - Phone:586-416-6290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018575225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist