1043154818 NPI number — KELLY ELIZABETH BOUTELLE GORDON

Table of content: KELLY ELIZABETH BOUTELLE GORDON (NPI 1043154818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043154818 NPI number — KELLY ELIZABETH BOUTELLE GORDON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
KELLY
Provider Middle Name:
ELIZABETH BOUTELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOUTELLE
Provider Other First Name:
KELLY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043154818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N2198
Provider Second Line Business Mailing Address:
CB7010
Provider Business Mailing Address City Name:
CHAPEL HILL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27599-7010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-966-4873
Provider Business Mailing Address Fax Number:
919-966-5136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N2198
Provider Second Line Business Practice Location Address:
CB7010
Provider Business Practice Location Address City Name:
CHAPEL HILL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27599-7010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-966-4873
Provider Business Practice Location Address Fax Number:
919-966-5136
Provider Enumeration Date:
04/14/2026

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: 390200000X , 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)





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