1801091343 NPI number — KELLY PATE NGUYEN NP

Table of content: KELLY PATE NGUYEN NP (NPI 1801091343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801091343 NPI number — KELLY PATE NGUYEN NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NGUYEN
Provider First Name:
KELLY
Provider Middle Name:
PATE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PATE
Provider Other First Name:
KELLY
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1801091343
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 SE CARY PKWY
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
CARY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27518-7420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-463-1101
Provider Business Mailing Address Fax Number:
919-463-1110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1110 SE CARY PKWY
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
CARY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27518-7420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-463-1101
Provider Business Practice Location Address Fax Number:
919-463-1110
Provider Enumeration Date:
06/15/2007

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: 363L00000X , with the licence number:  201652 , 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: 7003970 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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