Healthcare Provider Details

I. General information

NPI: 1447955232
Provider Name (Legal Business Name): MARY KATHRYN ELLEDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 ERWIN RD
DURHAM NC
27705-4699
US

IV. Provider business mailing address

6804 BUCKHEAD DR
RALEIGH NC
27615-7003
US

V. Phone/Fax

Practice location:
  • Phone: 919-684-8111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number297433
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5021780
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: