Provider Demographics
NPI:1194301283
Name:GILL, KELLY CHRISTINE (LMT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:CHRISTINE
Last Name:GILL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 AZTEC AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE ROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87547-3405
Mailing Address - Country:US
Mailing Address - Phone:505-413-0632
Mailing Address - Fax:
Practice Address - Street 1:3500 TRINITY DR STE C5
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2221
Practice Address - Country:US
Practice Address - Phone:505-413-4061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-20
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5728225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist