Basic Information
| Provider Information | |||||||||
| NPI: | 1124335401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FETTER | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | OT | ||||||||
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| OtherLastName: | WEST | ||||||||
| OtherFirstName: | KELLI | ||||||||
| OtherMiddleName: | L. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8500 WOLF PEN BRANCH RD | ||||||||
| Address2: | |||||||||
| City: | PROSPECT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400598622 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 MIDLAND TRAIL | ||||||||
| Address2: | STE 1 & 2 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026331007 | ||||||||
| FaxNumber: | 5024370624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2010 | ||||||||
| LastUpdateDate: | 03/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | R4583 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.