Provider Demographics
NPI:1396127072
Name:ELMORE, KELLIE CHRISTINA (PT)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:CHRISTINA
Last Name:ELMORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1769 FAWN CIR
Mailing Address - Street 2:
Mailing Address - City:PACIFIC
Mailing Address - State:MO
Mailing Address - Zip Code:63069-4456
Mailing Address - Country:US
Mailing Address - Phone:636-271-2009
Mailing Address - Fax:
Practice Address - Street 1:1910 NURSING HOME RD
Practice Address - Street 2:
Practice Address - City:OWENSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65066-2844
Practice Address - Country:US
Practice Address - Phone:573-437-4055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist