Basic Information
| Provider Information | |||||||||
| NPI: | 1427075886 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIEDMEYER-DAVIS | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 NW CARY PARKWAY | ||||||||
| Address2: | SUITE 301 DUNN PHYSICAL THERAPY | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193880111 | ||||||||
| FaxNumber: | 9193888668 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 NW CARY PARKWAY | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193880111 | ||||||||
| FaxNumber: | 9193888668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7630 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 6698931 | 01 | NC | GHI | OTHER | 5102400 | 01 | NC | AETNA PPO | OTHER | 0784Q | 01 | NC | BCBS | OTHER | 2209325 | 01 | NC | AETNA HMO | OTHER |