Provider Demographics
NPI:1134613482
Name:LEPORE, KELSEY (ATC)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:LEPORE
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 1:909 E EMINENCE WAY
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4524
Mailing Address - Country:US
Mailing Address - Phone:401-487-1146
Mailing Address - Fax:
Practice Address - Street 1:1000 W BISHOP BLVD
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:IN
Practice Address - Zip Code:47446-1080
Practice Address - Country:US
Practice Address - Phone:812-849-3663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002213A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer