Provider Demographics
NPI:1235218033
Name:MCDONALD, KELLY ANN (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:MCDONALD
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 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:16615 W CATAWBA AVE STE D
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-8989
Practice Address - Country:US
Practice Address - Phone:704-987-4322
Practice Address - Fax:704-987-7959
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT8400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT8400OtherSTATE LISC NUMBER
GA202I655415Medicare PIN