Provider Demographics
NPI:1720625544
Name:KNIPPA, KELLI (LAT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:KNIPPA
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 RANCHO BUENO DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-9520
Mailing Address - Country:US
Mailing Address - Phone:512-299-6389
Mailing Address - Fax:
Practice Address - Street 1:4202 44TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-3304
Practice Address - Country:US
Practice Address - Phone:512-299-6389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-01
Last Update Date:2019-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT76892083S0010X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10585751OtherANY