Provider Demographics
NPI:1679323299
Name:KELLY, GLEN AARON
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:AARON
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 WAGONER RD
Mailing Address - Street 2:
Mailing Address - City:ELON
Mailing Address - State:NC
Mailing Address - Zip Code:27244-9222
Mailing Address - Country:US
Mailing Address - Phone:919-423-7985
Mailing Address - Fax:
Practice Address - Street 1:3802 WADE COBLE DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-9765
Practice Address - Country:US
Practice Address - Phone:336-538-1522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA4734225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant