Provider Demographics
NPI:1336542588
Name:WRIGHT, KELLY LANE (MAT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LANE
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:802 MOTT SHUE DR SW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-0311
Mailing Address - Country:US
Mailing Address - Phone:919-691-5402
Mailing Address - Fax:
Practice Address - Street 1:300 PITTS SCHOOL RD SW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-3903
Practice Address - Country:US
Practice Address - Phone:704-788-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-02
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer