Basic Information
| Provider Information | |||||||||
| NPI: | 1689956641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | MALUTA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MALUTA | ||||||||
| OtherFirstName: | ANDREA | ||||||||
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| OtherCredential: | P.A | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13808 PROFESSIONAL CENTER DR STE 302 | ||||||||
| Address2: | |||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280787948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043774009 | ||||||||
| FaxNumber: | 7046024381 | ||||||||
| Practice Location | |||||||||
| Address1: | 2015 RANDOLPH RD STE 208 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043774009 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2011 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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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 | 001004126 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2531PA | 05 | SC | MEDICAID | 1689956641 | 05 | NC | MEDICAID |