Provider Demographics
NPI:1689123473
Name:DANIELS, KELLY (LAT ATC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:DANIELS
Suffix:
Gender:F
Credentials:LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 N ROAD ST
Mailing Address - Street 2:BLDG 7
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3365
Mailing Address - Country:US
Mailing Address - Phone:252-384-2360
Mailing Address - Fax:252-384-2359
Practice Address - Street 1:1134 N ROAD ST
Practice Address - Street 2:BLDG 7
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3365
Practice Address - Country:US
Practice Address - Phone:252-384-2360
Practice Address - Fax:252-384-2359
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer