Provider Demographics
NPI:1265726459
Name:EVERSOLE, KELLY (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:EVERSOLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 KIAWAH DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-1195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 PERIMETER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4121
Practice Address - Country:US
Practice Address - Phone:859-257-4576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-05
Last Update Date:2011-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004477174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist