Provider Demographics
NPI:1013562982
Name:KELLOMAKI, RACHEL CATHERINE (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:CATHERINE
Last Name:KELLOMAKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:CATHERINE
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 87388
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-7388
Mailing Address - Country:US
Mailing Address - Phone:910-323-2477
Mailing Address - Fax:910-323-5931
Practice Address - Street 1:1880 QUIET CV
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3857
Practice Address - Country:US
Practice Address - Phone:910-323-2477
Practice Address - Fax:910-323-5931
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-07
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09069363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant