Provider Demographics
NPI:1417058686
Name:STUART, KELLIE KING (PT)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:KING
Last Name:STUART
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 1:2200 E PARRISH AVE
Mailing Address - Street 2:LL 101
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1449
Mailing Address - Country:US
Mailing Address - Phone:270-684-2733
Mailing Address - Fax:270-684-3326
Practice Address - Street 1:2200 E PARRISH AVE
Practice Address - Street 2:LL 101
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1449
Practice Address - Country:US
Practice Address - Phone:270-684-2733
Practice Address - Fax:270-684-3326
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002853225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5025604Medicare PIN