Provider Demographics
NPI:1215506761
Name:KELLY, KACI CATHLEEN
Entity type:Individual
Prefix:
First Name:KACI
Middle Name:CATHLEEN
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5728 WOODALE DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912-2616
Mailing Address - Country:US
Mailing Address - Phone:865-240-1929
Mailing Address - Fax:
Practice Address - Street 1:719 S MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-2809
Practice Address - Country:US
Practice Address - Phone:615-480-4792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-20
Last Update Date:2021-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5226225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant