MEDICARE: KELLI NICOLE KING FNP

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	363LF0000X	Family Nurse Practitioner	5006033	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235473232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI NICOLE KING FNP

Provider Business Mailing Address
First Line	:	1221 FLORAL PKWY
Second Line	:	UNIT 105
City	:	WILMINGTON
State	:	NC
Zip	:	28403-6238
Country	:	US
Telephone Number	:	910-799-6262
Fax Number	:	910-799-6261

Provider Business Practice Location Address
First Line	:	1221 FLORAL PKWY
Second Line	:	UNIT 105
City	:	WILMINGTON
State	:	NC
Zip	:	28403-6238
Country	:	US
Telephone Number	:	910-799-6262
Fax Number	:	910-799-6261

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

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	02/20/2014

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