Provider Demographics
NPI:1639792401
Name:BOSS, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 E 7TH ST STE 206
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-4319
Mailing Address - Country:US
Mailing Address - Phone:704-333-1052
Mailing Address - Fax:704-333-1054
Practice Address - Street 1:2630 E 7TH ST STE 206
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-4319
Practice Address - Country:US
Practice Address - Phone:704-333-1052
Practice Address - Fax:704-333-1054
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP19369225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist