Provider Demographics
NPI:1316069057
Name:WIMMER, KELLY (PTA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WIMMER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 HEDGEROW DR
Mailing Address - Street 2:
Mailing Address - City:SOUDERTON
Mailing Address - State:PA
Mailing Address - Zip Code:18964-1976
Mailing Address - Country:US
Mailing Address - Phone:215-721-0384
Mailing Address - Fax:
Practice Address - Street 1:660 N BROAD ST
Practice Address - Street 2:ELM TERRACE GARDENS
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-2361
Practice Address - Country:US
Practice Address - Phone:215-362-6087
Practice Address - Fax:215-412-3495
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE001685L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant