Provider Demographics
NPI:1770111999
Name:RUNYON, KELSEY LYNN (PT, DPT)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNN
Last Name:RUNYON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 N JESSE RD
Mailing Address - Street 2:
Mailing Address - City:NOBLE
Mailing Address - State:IL
Mailing Address - Zip Code:62868-2815
Mailing Address - Country:US
Mailing Address - Phone:618-395-6031
Mailing Address - Fax:618-395-6289
Practice Address - Street 1:800 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2553
Practice Address - Country:US
Practice Address - Phone:618-395-6031
Practice Address - Fax:618-395-6289
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070020155208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation