Healthcare Provider Details

I. General information

NPI: 1376735068
Provider Name (Legal Business Name): KELLY C. MCKAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 OWEN DR
FAYETTEVILLE NC
28304-3424
US

IV. Provider business mailing address

34 CAPRON ST
FORT BRAGG NC
28307-2038
US

V. Phone/Fax

Practice location:
  • Phone: 706-577-6404
  • Fax:
Mailing address:
  • Phone: 706-577-6404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1634066
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: