Healthcare Provider Details

I. General information

NPI: 1598743114
Provider Name (Legal Business Name): KELLI B MAYFIELD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CABARRUS AVE E
CONCORD NC
28025-3699
US

IV. Provider business mailing address

819 FOREST AVE
ORONO ME
04473-3013
US

V. Phone/Fax

Practice location:
  • Phone: 980-960-2563
  • Fax:
Mailing address:
  • Phone: 207-217-4275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number309109-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number010127185
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number018447
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberTD091103
License Number StateME
# 5
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number9500998
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: