| NPI | 1386201648 |
|---|---|
| Former Name | KELLI ANNE THIEDERMAN |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126003154) |
| Enumeration Date | 2019-05-22 |
| Last Update Date | 2019-05-22 |