Provider Demographics
NPI:1164768008
Name:AVANT, KELLY (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:AVANT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WOMACK ARMY MEDICAL CTR
Mailing Address - Street 2:2817 REILLY RD
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE MADIGAN ARMY MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-1518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0011981225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist