Healthcare Provider Details

I. General information

NPI: 1841031192
Provider Name (Legal Business Name): KAELI ANN RYAN PT, DPT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9020 SENCA DR
WILMINGTON NC
28411-6679
US

IV. Provider business mailing address

9020 SENCA DR
WILMINGTON NC
28411-6679
US

V. Phone/Fax

Practice location:
  • Phone: 910-264-9317
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP23204
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-5362
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: