1104340769 NPI number — MISS MALLORY A. KELLY PT, DPT

Table of content: MISS MALLORY A. KELLY PT, DPT (NPI 1104340769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104340769 NPI number — MISS MALLORY A. KELLY PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
MALLORY
Provider Middle Name:
A.
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EPPING
Provider Other First Name:
MALLORY
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104340769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3301 W FOREST HOME AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53215-2843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 N LAKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWIN LAKES
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53181-9436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-877-2124
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)