Healthcare Provider Details

I. General information

NPI: 1801187059
Provider Name (Legal Business Name): KELLY JEAN DUFFY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 KINDERTON BLVD
ADVANCE NC
27006-7302
US

IV. Provider business mailing address

1701 WESTCHESTER DR STE 850
HIGH POINT NC
27262-7008
US

V. Phone/Fax

Practice location:
  • Phone: 336-998-9742
  • Fax: 336-998-9410
Mailing address:
  • Phone: 336-802-2400
  • Fax: 336-802-2534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2014-00111
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number172764
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: