Basic Information
| Provider Information | |||||||||
| NPI: | 1346430691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASON | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | CASSEDY | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 176 BLUEBERRY LN | ||||||||
| Address2: | |||||||||
| City: | RAEFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283768328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042473168 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2645 MERIDIAN PKWY STE 323 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277134232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9842278902 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 124340 | GA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 124340 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 5008052 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 005599973A | 05 | GA | MEDICAID |