Provider Demographics
NPI:1063484889
Name:FONVILLE, KELLY ANNE (MS OTR IL)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANNE
Last Name:FONVILLE
Suffix:
Gender:F
Credentials:MS OTR IL
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:ANNE
Other - Last Name:NAPIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS OTR IL
Mailing Address - Street 1:3301 OVERBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CONOVER
Mailing Address - State:NC
Mailing Address - Zip Code:28613-8227
Mailing Address - Country:US
Mailing Address - Phone:828-256-9488
Mailing Address - Fax:
Practice Address - Street 1:3301 OVERBROOK DR
Practice Address - Street 2:
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-8227
Practice Address - Country:US
Practice Address - Phone:828-256-9488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5956225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC185536OtherMEDCOST
NC141MYOtherBCBS
NC7301880Medicaid