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General NPI Number Information
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NPI Number | 1912084013
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Entity Type | Individual
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Provider Name | KIM KERRY NEELY PAC
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Gender | Female
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 04/18/2016
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Provider Practice Location Address
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Address Line | 3627 BEATTIES FORD RD
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City | CHARLOTTE
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State | NC
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Zip | 28216-3249
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Country | US
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Telephone | 704-335-0806
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Fax | 704-334-2073
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Provider Business Mailing Address
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Address Line | 12102 BOTTLEBRUSH PL
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City | CHARLOTTE
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State | NC
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Zip | 28277-1793
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Country | US
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Telephone | 704-752-0130
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 102318
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License Number State | NC
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