Provider Demographics
NPI:1043554249
Name:KOCJANCIC, KELSEY
Entity Type:Individual
Prefix:MR
First Name:KELSEY
Middle Name:
Last Name:KOCJANCIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E BLAND ST
Mailing Address - Street 2:APT 281
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-6142
Mailing Address - Country:US
Mailing Address - Phone:814-335-2542
Mailing Address - Fax:
Practice Address - Street 1:222 E BLAND ST
Practice Address - Street 2:APT 281
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-6142
Practice Address - Country:US
Practice Address - Phone:814-335-2542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-12
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC241335163W00000X
NC90996367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse