Provider Demographics
NPI:1063521953
Name:HAVENS, KELLY LYNN (ATC)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYNN
Last Name:HAVENS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 ASPEN PINES DR
Mailing Address - Street 2:
Mailing Address - City:WILDER
Mailing Address - State:KY
Mailing Address - Zip Code:41071-0450
Mailing Address - Country:US
Mailing Address - Phone:859-801-7642
Mailing Address - Fax:
Practice Address - Street 1:13 CAROTHERS RD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:KY
Practice Address - Zip Code:41071-2415
Practice Address - Country:US
Practice Address - Phone:859-292-0001
Practice Address - Fax:859-292-0656
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer