Provider Demographics
NPI:1932135282
Name:FOSBERG, KELLY K (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:FOSBERG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 N TURQUOISE DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1398
Mailing Address - Country:US
Mailing Address - Phone:928-774-6626
Mailing Address - Fax:
Practice Address - Street 1:1485 N TURQUOISE DR
Practice Address - Street 2:SUITE 220
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1398
Practice Address - Country:US
Practice Address - Phone:928-774-6626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ108938Medicare PIN