Basic Information
| Provider Information | |||||||||
| NPI: | 1306846191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERGY | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | FOGARTY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1235 RAMSEY ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283014401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106096448 | ||||||||
| FaxNumber: | 9106097040 | ||||||||
| Practice Location | |||||||||
| Address1: | 1235 RAMSEY ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283014401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104333704 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 11/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 940034 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7000948 | 05 | NC | MEDICAID |