Healthcare Provider Details

I. General information

NPI: 1598207748
Provider Name (Legal Business Name): BRIDGET ANN KELLY PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 101ST AVE NE SUITE 140
BLAINE MN
55449-3400
US

IV. Provider business mailing address

8912 BLAKENEY PROFESSIONAL DR STE 100
CHARLOTTE NC
28277-6735
US

V. Phone/Fax

Practice location:
  • Phone: 763-703-3509
  • Fax: 763-703-3454
Mailing address:
  • Phone: 704-544-5353
  • Fax: 704-544-5382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10538
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: