MEDICARE: KELCI POPOVNAK PNP-AC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0222X	Critical Care Pediatric Nurse Practitioner	5020324	NC
2	363L00000X	Nurse Practitioner	5020324	NC

General Provider Information

NPI Number	:	1023853371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELCI POPOVNAK PNP-AC

Provider Business Mailing Address
First Line	:	MEDICAL CENTER BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27157-0001
Country	:	US
Telephone Number	:	336-716-0664
Fax Number	:	336-716-9634

Provider Business Practice Location Address
First Line	:	MEDICAL CENTER BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27157-0001
Country	:	US
Telephone Number	:	336-716-0664
Fax Number	:	336-716-9634

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2024
Last Update Date	:	02/17/2026

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