Provider Demographics
NPI:1801030499
Name:BOUTCHYARD, KELLY HALL (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:HALL
Last Name:BOUTCHYARD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:BOOTHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:136 CAROLINA CT W
Mailing Address - Street 2:
Mailing Address - City:MANTEO
Mailing Address - State:NC
Mailing Address - Zip Code:27954-9545
Mailing Address - Country:US
Mailing Address - Phone:252-338-2114
Mailing Address - Fax:252-338-2115
Practice Address - Street 1:5567 N CROATAN HWY
Practice Address - Street 2:
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-4090
Practice Address - Country:US
Practice Address - Phone:252-261-1556
Practice Address - Fax:252-261-6161
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0472640012Medicare NSC
VAVAA101464Medicare PIN