Provider Demographics
NPI:1770263451
Name:RIDDLE, KELLY STEWART (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:STEWART
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 HIGHWAY 70 EAST
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38012
Mailing Address - Country:US
Mailing Address - Phone:731-780-0778
Mailing Address - Fax:
Practice Address - Street 1:2060 RHINO XING
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-5201
Practice Address - Country:US
Practice Address - Phone:731-613-2214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0446631Medicaid