Provider Demographics
NPI:1053655928
Name:KELLY, DANIELLE RAE (PNP-PC)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:RAE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PNP-PC
Other - Prefix:MS
Other - First Name:DANIELLE
Other - Middle Name:RAE
Other - Last Name:LINGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP-PC
Mailing Address - Street 1:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:705 SUMMIT CROSSING PL STE 150
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2137
Practice Address - Country:US
Practice Address - Phone:704-671-6300
Practice Address - Fax:704-671-6307
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27745363LP0200X
NC5005940363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1053655928Medicaid