Basic Information
| Provider Information | |||||||||
| NPI: | 1790959617 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFERY | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLAND | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 676 DEKALB PIKE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | BLUE BELL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194221223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102700370 | ||||||||
| FaxNumber: | 6102700374 | ||||||||
| Practice Location | |||||||||
| Address1: | 341 10TH AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ROYERSFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194683807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107928100 | ||||||||
| FaxNumber: | 6107921535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2008 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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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 | 2251X0800X | PT019201 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.