| Doctor Name: | KELLY NICOLE EVANOVICH |
| NPI Number: | 1114274313 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PT, DPT, ATC |
| License Number: | 14.009513 |
| Business Practice Address: | 900 Northrop Rd Wallingford, CT - 064921997 |
| Business Phone Number: | 2039491534 |
| Business Fax Number: | |
| Mailing Address: | 64 Groveland Ter, NEWINGTON |
| State: | CT |
| Postal Code: | 061111614 |
| Phone Number: | 8607980147 |
| Fax Number: | |
| NPI Enumeration Date: | 08/07/2012 |
| NPI Last Update Date: | 08/07/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 2251X0800X |
| License Number: | 14.009513 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CT |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | Orthopedic |
| Taxonomy Definition: | |