Provider Demographics
NPI:1760357438
Name:STOVER, KELLI (PTA)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:STOVER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14442 18TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER
Mailing Address - State:ND
Mailing Address - Zip Code:58831-9595
Mailing Address - Country:US
Mailing Address - Phone:303-588-2838
Mailing Address - Fax:
Practice Address - Street 1:2100 W TETON BLVD
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-6040
Practice Address - Country:US
Practice Address - Phone:303-588-2838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-10
Last Update Date:2025-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1363A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant