1629180849 NPI number — MRS. MELISSA D KELLY CPNP

Table of content: MRS. MELISSA D KELLY CPNP (NPI 1629180849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629180849 NPI number — MRS. MELISSA D KELLY CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
MELISSA
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CPNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629180849
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 WESTCHESTER DR
Provider Second Line Business Mailing Address:
STE. 850
Provider Business Mailing Address City Name:
HIGH POINT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27262-7008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-802-2400
Provider Business Mailing Address Fax Number:
336-802-2534

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
802 GREEN VALLEY RD
Provider Second Line Business Practice Location Address:
STE. 210
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27408-7041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-510-5510
Provider Business Practice Location Address Fax Number:
336-810-5515
Provider Enumeration Date:
09/01/2006

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: 163WP0200X , with the licence number:  ARNP9169528 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: 5008997 , 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)

  • Identifier: 307942200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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