Basic Information
| Provider Information | |||||||||
| NPI: | 1154456028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILICHOSKI | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | A.T.,C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 PORTSMOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | GREENLAND | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038402134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6039693314 | ||||||||
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| Practice Location | |||||||||
| Address1: | 237 ROUTE 108 STE 101 | ||||||||
| Address2: | |||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038781517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037496686 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2255A2300X | 243 | NH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.