Provider Demographics
NPI:1053870188
Name:MAGINOT, KELLI
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:MAGINOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1973 CUMBRES PATIO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2734
Mailing Address - Country:US
Mailing Address - Phone:361-549-7678
Mailing Address - Fax:
Practice Address - Street 1:1350 CENTRAL AVE STE 105
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-6217
Practice Address - Country:US
Practice Address - Phone:505-662-3384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42792225100000X
NMPT5442225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist