Provider Demographics
NPI:1336894401
Name:KELLY, REBECCA ANN
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9105 W RYAN CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-2145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3700 E LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2008
Practice Address - Country:US
Practice Address - Phone:316-686-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-02393225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist