Provider Demographics
NPI:1356977524
Name:ZIMMERMAN, KELLY (ATC, LAT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W 49TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-3480
Mailing Address - Country:US
Mailing Address - Phone:317-940-8437
Mailing Address - Fax:
Practice Address - Street 1:510 W 49TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-3480
Practice Address - Country:US
Practice Address - Phone:317-940-8437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002041A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN36002041AOtherINDIANA PROFESSIONAL LICENSURE -ATHLETIC TRAINER BOARD
2000003809OtherBOARD OF CERTIFICATION, INC.