MEDICARE: MRS. AMY SUE KELLY 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	102882	NC

General Provider Information

NPI Number	:	1467486092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMY SUE KELLY PA-C

Provider Business Mailing Address
First Line	:	2930 HOLDEN BEACH ROAD
Second Line	:
City	:	SUPPLY
State	:	NC
Zip	:	28462-4096
Country	:	US
Telephone Number	:	910-842-5991
Fax Number	:

Provider Business Practice Location Address
First Line	:	2930 HOLDEN BEACH RD SW
Second Line	:
City	:	SUPPLY
State	:	NC
Zip	:	28462-5702
Country	:	US
Telephone Number	:	910-842-5991
Fax Number	:	910-842-5994

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	12/22/2011

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