Provider Demographics
NPI:1104974534
Name:RILEY, KELLY ANN (DPT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:RILEY
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 1:1409 AUDUBON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6749
Mailing Address - Country:US
Mailing Address - Phone:910-392-2240
Mailing Address - Fax:910-392-2242
Practice Address - Street 1:1409 AUDUBON BLVD STE B4
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6753
Practice Address - Country:US
Practice Address - Phone:910-392-2240
Practice Address - Fax:910-392-2242
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10422225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211961Medicaid