Provider Demographics
NPI:1366744963
Name:BOEHNING, KELLI
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:BOEHNING
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 1:1111 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-3871
Mailing Address - Country:US
Mailing Address - Phone:815-985-6985
Mailing Address - Fax:
Practice Address - Street 1:429 PHELPS AVE
Practice Address - Street 2:BLDG. 7 STE. 711
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2493
Practice Address - Country:US
Practice Address - Phone:815-985-6985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227002068225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist