=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104811959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY STEVENS PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2005
-----------------------------------------------------
Last Update Date | 12/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2635 LAWNDALE DR
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27408-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-867-4310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 601843
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28260-1843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-322-1000
-----------------------------------------------------
Fax | 406-322-5207
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 055.0031677
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 41208
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA3513
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0010-11495
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------