Provider Demographics
NPI:1609513472
Name:WILD, KELLY C (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:WILD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
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Mailing Address - Street 1:981 HIGH HOUSE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-3510
Mailing Address - Country:US
Mailing Address - Phone:919-388-0111
Mailing Address - Fax:919-388-8668
Practice Address - Street 1:110 MAIN ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-3319
Practice Address - Country:US
Practice Address - Phone:919-853-7183
Practice Address - Fax:919-853-7184
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NCP20862225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist