Provider Demographics
NPI:1205917994
Name:RAFFERTY, KERRY ANN (PT)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:ANN
Last Name:RAFFERTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 TERRA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-7671
Mailing Address - Country:US
Mailing Address - Phone:631-512-3267
Mailing Address - Fax:843-353-0167
Practice Address - Street 1:269 TERRA VISTA DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7671
Practice Address - Country:US
Practice Address - Phone:631-512-3267
Practice Address - Fax:843-353-0167
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0233551225100000X
SC225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ14L61Medicare ID - Type Unspecified