Healthcare Provider Details

I. General information

NPI: 1710911375
Provider Name (Legal Business Name): KELLY MARIE WAICUS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6118 FARRINGTON RD STE A
CHAPEL HILL NC
27517-8108
US

IV. Provider business mailing address

5221 PARAMOUNT PKWY STE 420
MORRISVILLE NC
27560-5491
US

V. Phone/Fax

Practice location:
  • Phone: 984-974-9977
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number9801106
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9801106
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: