Basic Information
| Provider Information | |||||||||
| NPI: | 1760507958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARPENTER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | BERGERON | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 360 | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287790360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883396065 | ||||||||
| FaxNumber: | 8285384441 | ||||||||
| Practice Location | |||||||||
| Address1: | 2645 MERIDIAN PKWY STE 323 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277134232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9842278902 | ||||||||
| FaxNumber: | 8448136747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5002933 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1760507958 | 05 | NC | MEDICAID | P02479422 | 01 | NC | RAILROAD MEDICARE | OTHER | NCE536B | 01 | NC | MEDICARE | OTHER | 182E4 | 01 | NC | BCBS | OTHER |