Provider Demographics
NPI:1770063083
Name:KELLY, MEREDITH (DPT, CERT DN, BFR)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:DPT, CERT DN, BFR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603949
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3949
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:10000 CAMBRIDGE VILLAGE LOOP
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-7707
Practice Address - Country:US
Practice Address - Phone:919-350-1508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP16919225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1770063083Medicaid