Healthcare Provider Details

I. General information

NPI: 1326093956
Provider Name (Legal Business Name): KELLY RAE DURHAM PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 CEDAR POINT BLVD STE F
CEDAR POINT NC
28584-1030
US

IV. Provider business mailing address

1165 CEDAR POINT BLVD STE F
CEDAR POINT NC
28584-1030
US

V. Phone/Fax

Practice location:
  • Phone: 252-364-4690
  • Fax: 252-606-4325
Mailing address:
  • Phone: 252-364-4690
  • Fax: 252-606-4325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number101510
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: