Healthcare Provider Details

I. General information

NPI: 1104811959
Provider Name (Legal Business Name): KELLY STEVENS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY STEVENS-PICO PA

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 LAWNDALE DR
GREENSBORO NC
27408-4802
US

IV. Provider business mailing address

PO BOX 601843
CHARLOTTE NC
28260-1843
US

V. Phone/Fax

Practice location:
  • Phone: 336-867-4310
  • Fax:
Mailing address:
  • Phone: 406-322-1000
  • Fax: 406-322-5207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055.0031677
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number41208
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA3513
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-11495
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: