Provider Demographics
NPI:1487750527
Name:PENROSE, KELLEY B (MPT,CCI)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:B
Last Name:PENROSE
Suffix:
Gender:F
Credentials:MPT,CCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 796
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-0796
Mailing Address - Country:US
Mailing Address - Phone:574-238-6397
Mailing Address - Fax:574-329-5243
Practice Address - Street 1:10420 ACORN CT
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:IN
Practice Address - Zip Code:46561-9330
Practice Address - Country:US
Practice Address - Phone:574-238-6397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21304225100000X
IN05-007738A2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891690000Medicaid
FLAB762ZOtherMEDICARE PTAN