Provider Demographics
NPI:1366619207
Name:WHITE, KELLI LYNNE (PT)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:LYNNE
Last Name:WHITE
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 1:20633 GAS POINT RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:COTTONWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:96022-9296
Mailing Address - Country:US
Mailing Address - Phone:530-347-4195
Mailing Address - Fax:530-347-4192
Practice Address - Street 1:20633 GAS POINT RD
Practice Address - Street 2:SUITE J
Practice Address - City:COTTONWOOD
Practice Address - State:CA
Practice Address - Zip Code:96022-9296
Practice Address - Country:US
Practice Address - Phone:530-347-4195
Practice Address - Fax:530-347-4192
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30152225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist