Provider Demographics
NPI:1386997476
Name:PONDER, KELLIE C
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:C
Last Name:PONDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:STAAB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 LOTHROP ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-2536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:821 HERON RD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32926-2320
Practice Address - Country:US
Practice Address - Phone:814-227-3590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-26
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT16047225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist