Provider Demographics
NPI:1174131098
Name:BRENNAN, KELLY LEANN (PTA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEANN
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LEANN
Other - Last Name:BOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2121 W MAIN ST APT 3114
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-9098
Mailing Address - Country:US
Mailing Address - Phone:619-852-5489
Mailing Address - Fax:
Practice Address - Street 1:8679 E SAN ALBERTO
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4368
Practice Address - Country:US
Practice Address - Phone:619-852-5489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ014020225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant