Basic Information
| Provider Information | |||||||||
| NPI: | 1245235308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENNES | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7721 SW 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666151215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852715533 | ||||||||
| FaxNumber: | 7852718818 | ||||||||
| Practice Location | |||||||||
| Address1: | 5220 SW 17TH | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666042459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852715533 | ||||||||
| FaxNumber: | 7852718818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11-03250 | KS | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 140418 | 01 | BLUE CROSS | OTHER |