Healthcare Provider Details

I. General information

NPI: 1780579862
Provider Name (Legal Business Name): ERIN COLLEEN KELLY
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 QUEENS RD STE 430
CHARLOTTE NC
28204-3579
US

IV. Provider business mailing address

106 DENTON RD
MADISONVILLE TN
37354-7807
US

V. Phone/Fax

Practice location:
  • Phone: 980-302-6300
  • Fax: 980-302-6305
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-17021
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: