Provider Demographics
NPI:1578804258
Name:KELLEY, KIMBERLY B (DPT, PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:B
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10419 GILLATE RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER
Mailing Address - State:NY
Mailing Address - Zip Code:14005-9767
Mailing Address - Country:US
Mailing Address - Phone:716-560-0976
Mailing Address - Fax:
Practice Address - Street 1:5 FIRST VILLAGE DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8724
Practice Address - Country:US
Practice Address - Phone:910-235-2713
Practice Address - Fax:910-235-4663
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13320225100000X
NY033899225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist