MEDICARE: EMMA KELLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	5021112	NC

General Provider Information

NPI Number	:	1154144137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMA KELLEY

Provider Business Mailing Address
First Line	:	3641 TRYCLAN DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-1329
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3641 TRYCLAN DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-1329
Country	:	US
Telephone Number	:	315-256-3170
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2024
Last Update Date	:	01/03/2025

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Directions to “ EMMA KELLEY ” Practice Location

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