Basic Information
| Provider Information | |||||||||
| NPI: | 1588656284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSBORN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BS PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRY | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BS PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10004 204TH AVE E | ||||||||
| Address2: | STE 3100 | ||||||||
| City: | BONNEY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983916539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538637510 | ||||||||
| FaxNumber: | 2538635970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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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 | 225100000X | PT00006442 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8334062 | 05 | WA | MEDICAID | 5342OB | 01 | WA | REGENCE BS | OTHER | 650023301 | 01 | WA | R/R MED PC | OTHER | 158113 | 01 | WA | DEPT OF L&I | OTHER | 0291100 | 01 | WA | DEPT. OF LABOR AND INDUSTRIES | OTHER | 8936257 | 01 | WA | CRIME VICTIMS | OTHER |