Healthcare Provider Details

I. General information

NPI: 1104135979
Provider Name (Legal Business Name): ANDREA W KELLY RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 OLD LILESVILLE ROAD
WADESBORO NC
28170-2820
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR SUITE 100
CONCORD NC
28025-1894
US

V. Phone/Fax

Practice location:
  • Phone: 704-694-6588
  • Fax:
Mailing address:
  • Phone: 704-939-1118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number111797
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: