Provider Demographics
NPI:1407094642
Name:CONEY PACIOUS, KELLY LEE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LEE
Last Name:CONEY PACIOUS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:LEE
Other - Last Name:CONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:PO BOX 1036
Mailing Address - Street 2:SHINING HOPE FARMS
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120
Mailing Address - Country:US
Mailing Address - Phone:704-827-3788
Mailing Address - Fax:
Practice Address - Street 1:328 WHIPPOORWILL LANE
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120
Practice Address - Country:US
Practice Address - Phone:704-827-3788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP119572251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics