Healthcare Provider Details

I. General information

NPI: 1760906184
Provider Name (Legal Business Name): KELLY GRANT EZZELL ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 DOCK ST
WILMINGTON NC
28401-4936
US

IV. Provider business mailing address

1501 DOCK ST
WILMINGTON NC
28401-4936
US

V. Phone/Fax

Practice location:
  • Phone: 910-254-9898
  • Fax:
Mailing address:
  • Phone: 910-254-9898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number319192
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberARNP9384638
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9384638
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: