Provider Demographics
NPI:1871841775
Name:WILSON, KELLY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:825 DAVIS ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-7013
Mailing Address - Country:US
Mailing Address - Phone:540-552-5100
Mailing Address - Fax:540-552-5700
Practice Address - Street 1:825 DAVIS ST
Practice Address - Street 2:SUITE B
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7013
Practice Address - Country:US
Practice Address - Phone:540-552-5100
Practice Address - Fax:540-552-5700
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA2305207728225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist