Basic Information
| Provider Information | |||||||||
| NPI: | 1629180849 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 WESTCHESTER DR | ||||||||
| Address2: | STE. 850 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272627008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022400 | ||||||||
| FaxNumber: | 3368022534 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 GREEN VALLEY RD | ||||||||
| Address2: | STE. 210 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274087041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365105510 | ||||||||
| FaxNumber: | 3368105515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 10/17/2016 | ||||||||
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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 | 163WP0200X | ARNP9169528 | FL | N | Nursing Service Providers | Registered Nurse | Pediatrics | 363LP0200X | 5008997 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 307942200 | 05 | FL | MEDICAID |