MEDICARE: KIRSTEN KELLY

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	2255A2300X	Athletic Trainer	LAT-2857	NC

General Provider Information

NPI Number	:	1134574536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRSTEN KELLY

Provider Business Mailing Address
First Line	:	1909 COVENGTON WAY UNIT 102
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27858-7888
Country	:	US
Telephone Number	:	252-578-8545
Fax Number	:

Provider Business Practice Location Address
First Line	:	1909 COVENGTON WAY UNIT 102
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27858-7888
Country	:	US
Telephone Number	:	252-578-8545
Fax Number	:

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

Provider Enumeration Date	:	05/04/2016
Last Update Date	:	05/04/2016

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Directions to “ KIRSTEN KELLY ” Practice Location

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