Provider Demographics
NPI:1255070637
Name:KELLEY, NATHAN R (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:R
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 BOONE RD
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-4967
Mailing Address - Country:US
Mailing Address - Phone:336-932-9744
Mailing Address - Fax:336-627-8421
Practice Address - Street 1:405 BOONE RD
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-4967
Practice Address - Country:US
Practice Address - Phone:336-932-9744
Practice Address - Fax:336-627-8421
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP21347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist