Basic Information
| Provider Information | |||||||||
| NPI: | 1316066079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'HARA | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | HARNEY | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 16525 HOLLY CREST LN STE 150 | ||||||||
| Address2: | |||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280784911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043848720 | ||||||||
| FaxNumber: | 7043848747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5002520 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1316066079 | 05 | NC | MEDICAID |