Provider Demographics
NPI:1033482526
Name:SANBORN, KELLY CHRISTINE (PT, DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:CHRISTINE
Last Name:SANBORN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 THIELEN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-9613
Mailing Address - Country:US
Mailing Address - Phone:763-497-1153
Mailing Address - Fax:763-497-5256
Practice Address - Street 1:703 THIELEN DR
Practice Address - Street 2:
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-9613
Practice Address - Country:US
Practice Address - Phone:763-497-1153
Practice Address - Fax:763-497-5256
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-15
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist