Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 10422 | NC |
Y | 2251P0200X | Physical Therapist - Pediatrics | 10422 | NC |
NPI | 1104974534 |
---|---|
Provider Name | Mrs. Kelly Ann Riley |
First Address | Wilmington, NC 28403-4749 |
Second Address | Wilmington, NC 28403-4749 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/01/2007 |
Last Update Date | 01/07/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7211961 | (05) | NC |