Basic Information
| Provider Information | |||||||||
| NPI: | 1407102585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARPENTER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUNN | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2002 W SUNSET DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825012283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078567021 | ||||||||
| FaxNumber: | 3078565546 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 W SUNSET DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825012283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078567021 | ||||||||
| FaxNumber: | 3078565546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2012 | ||||||||
| LastUpdateDate: | 07/26/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA-0756 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.