Provider Demographics
NPI:1902235146
Name:DAVIS, KELLY NICOLE (DPT, ATC, COMT, CSCS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:NICOLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DPT, ATC, COMT, CSCS
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:DAVIS
Other - Last Name:PUPELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT, ATC, COMT, CSCS
Mailing Address - Street 1:1761 PINEHURST PLZ
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-3889
Mailing Address - Country:US
Mailing Address - Phone:610-256-2860
Mailing Address - Fax:
Practice Address - Street 1:1761 PINEHURST PLZ
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-3889
Practice Address - Country:US
Practice Address - Phone:610-256-2860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 28657225100000X
FLAL 37072255A2300X
CA299323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer