Provider Demographics
NPI:1831442649
Name:PHIPPS, KELLEY A
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:A
Last Name:PHIPPS
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 1:1209 NW 19TH ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2016
Mailing Address - Country:US
Mailing Address - Phone:208-949-7569
Mailing Address - Fax:
Practice Address - Street 1:1209 NW 19TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2016
Practice Address - Country:US
Practice Address - Phone:208-949-7569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist