Provider Demographics
NPI:1154523116
Name:WHITE, KELLY QUINLAN (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:QUINLAN
Last Name:WHITE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MICHELLE
Other - Last Name:QUINLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-745-2273
Mailing Address - Fax:270-780-0490
Practice Address - Street 1:1681 NORMAL DRIVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101
Practice Address - Country:US
Practice Address - Phone:270-745-2273
Practice Address - Fax:270-780-0490
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005589225100000X
CT009056225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT33678OtherLICENSE
CT009056OtherCT STATE LICENSE