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General NPI Number Information
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NPI Number | 1699152025
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Entity Type | Individual
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Provider Name | CRYSTAL KELLY RN, FNP
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Gender | Female
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Dates
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Enumeration Date | 05/06/2015
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Last Update Date | 05/06/2015
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Provider Practice Location Address
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Address Line | 903 NORTHEAST DR SUITE 301
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City | DAVIDSON
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State | NC
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Zip | 28036-7416
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Country | US
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Telephone | 704-894-9309
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Fax |
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Provider Business Mailing Address
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Address Line | 143 DRAPER DR
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City | STATESVILLE
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State | NC
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Zip | 28625-2541
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Country | US
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Telephone | 704-682-3194
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 200588
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License Number State | NC
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