Provider Demographics
NPI:1285170209
Name:FIALA, KELLY ANN (MOTR/L)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:FIALA
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:630 KNOLLSHIRE WAY
Mailing Address - Street 2:
Mailing Address - City:DARDENNE PRAIRIE
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8376
Mailing Address - Country:US
Mailing Address - Phone:636-695-4330
Mailing Address - Fax:
Practice Address - Street 1:35 VILLA SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:NEW MADRID
Practice Address - State:MO
Practice Address - Zip Code:63869-1230
Practice Address - Country:US
Practice Address - Phone:573-621-3126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-14
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005028265225XP0019X, 225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation