Provider Demographics
NPI:1255466231
Name:VITZ, KELLY ANNE (PT)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANNE
Last Name:VITZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4000
Mailing Address - Street 2:PHYSICAL THERAPY DEPARTMENT
Mailing Address - City:POLACCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86042-4000
Mailing Address - Country:US
Mailing Address - Phone:928-737-6130
Mailing Address - Fax:928-737-6153
Practice Address - Street 1:HWY 264 MP 388
Practice Address - Street 2:HHCC - PHYSICAL THERAPY DEPARTMENT
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042-4000
Practice Address - Country:US
Practice Address - Phone:928-737-6130
Practice Address - Fax:928-737-6153
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7277225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist