Provider Demographics
NPI:1588656284
Name:OSBORN, KELLY A (BS PT)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:OSBORN
Suffix:
Gender:F
Credentials:BS PT
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:FRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:10004 204TH AVE E
Practice Address - Street 2:STE 3100
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-6539
Practice Address - Country:US
Practice Address - Phone:253-863-7510
Practice Address - Fax:253-863-5970
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006442225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8334062Medicaid
WA5342OBOtherREGENCE BS
WA650023301OtherR/R MED PC
WA158113OtherDEPT OF L&I
WA0291100OtherDEPT. OF LABOR AND INDUSTRIES
WA8936257OtherCRIME VICTIMS
WA8334062Medicaid
WAAB28680Medicare ID - Type UnspecifiedPIERCE COUNTY