Basic Information
| Provider Information | |||||||||
| NPI: | 1598151177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | ALLIE | ||||||||
| MiddleName: | BLACK | ||||||||
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| Credential: | P.A.C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BLACK | ||||||||
| OtherFirstName: | ALLIE | ||||||||
| OtherMiddleName: | DUKE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4601 PARK ROAD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2001 VAIL AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 06/13/2018 | ||||||||
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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 | 363A00000X | PA9108675 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2733 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0010-05675 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2733 | 01 | SC | MEDICAL LICENSE | OTHER | 0010-05675 | 01 | NC | MEDICAL LICENSE | OTHER | 1598151177 | 05 | NC | MEDICAID |