Healthcare Provider Details

I. General information

NPI: 1396454724
Provider Name (Legal Business Name): KELLY ANNETTE CUDD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 ALLENDALE DR
FOREST CITY NC
28043-2874
US

IV. Provider business mailing address

PO BOX 743070
ATLANTA GA
30374-3070
US

V. Phone/Fax

Practice location:
  • Phone: 828-374-0904
  • Fax:
Mailing address:
  • Phone: 645-604-3048
  • Fax: 864-560-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26794
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5019657
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: