1336542588 NPI number — KELLY LANE WRIGHT MAT, LAT, ATC

Table of content: KELLY LANE WRIGHT MAT, LAT, ATC (NPI 1336542588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336542588 NPI number — KELLY LANE WRIGHT MAT, LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WRIGHT
Provider First Name:
KELLY
Provider Middle Name:
LANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MAT, LAT, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LANE
Provider Other First Name:
KELLY
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LAT, ATC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336542588
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
802 MOTT SHUE DR SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28027-0311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-691-5402
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 PITTS SCHOOL RD SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28027-3903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-788-4500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/02/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  1959 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)