MEDICARE: MRS. JENNIFER NILAND KERLEY PA-C

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	363A00000X	Physician Assistant	0010-01707	NC

General Provider Information

NPI Number	:	1104066117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER NILAND KERLEY PA-C

Provider Business Mailing Address
First Line	:	PO BOX 751803
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1803
Country	:	US
Telephone Number	:	336-893-2420
Fax Number	:	336-893-2431

Provider Business Practice Location Address
First Line	:	7130 VILLAGE MEDICAL CIR
Second Line	:
City	:	CLEMMONS
State	:	NC
Zip	:	27012-8004
Country	:	US
Telephone Number	:	336-893-2420
Fax Number	:	336-893-2431

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

Provider Enumeration Date	:	03/03/2009
Last Update Date	:	10/28/2020

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