Healthcare Provider Details

I. General information

NPI: 1558738922
Provider Name (Legal Business Name): PORNPILAI KECK NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 PROVIDENCE RD
CHARLOTTE NC
28207-1218
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-481-8655
  • Fax:
Mailing address:
  • Phone: 336-481-8655
  • Fax: 336-277-9165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5020321
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF307124
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: