MEDICARE: KELLY KIRKMAN GRANT 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	363L00000X	Nurse Practitioner	200614	NC
2	363LF0000X	Family Nurse Practitioner	200614	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200614	OTHER	NC	PE#

General Provider Information

NPI Number	:	1649274002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY KIRKMAN GRANT FNP

Provider Business Mailing Address
First Line	:	510 N ELAM AVE STE 202
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27403-1177
Country	:	US
Telephone Number	:	336-299-3183
Fax Number	:	336-299-1762

Provider Business Practice Location Address
First Line	:	510 N ELAM AVE STE 202
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27403-1177
Country	:	US
Telephone Number	:	336-299-3183
Fax Number	:	336-299-1762

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

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	04/24/2018

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