Basic Information
| Provider Information | |||||||||
| NPI: | 1720659469 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLIS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEONARD | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 213 N CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | LOUISBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275492530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524126484 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 MANNING DR | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275144220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9849741401 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2021 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0000X | 5014658 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
| ID | Type | State | Issuer | Description | 5014658 | 01 | NC | NC BOARD OF NURSING | OTHER |