Basic Information
| Provider Information | |||||||||
| NPI: | 1649394941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REPKA | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEGENHARDT | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1070 COSENZA CT | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180408094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 290 RED SCHOOL LN | ||||||||
| Address2: | |||||||||
| City: | PHILLIPSBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088652276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088592800 | ||||||||
| FaxNumber: | 9088591866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 01/17/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01140000 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 017307 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.