Provider Demographics
NPI:1104375112
Name:GREEN HARMAN, KELSEY ELENA (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:ELENA
Last Name:GREEN HARMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:ELENA
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1995 WELLNESS BLVD STE 110&210
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110
Practice Address - Country:US
Practice Address - Phone:704-384-1140
Practice Address - Fax:704-384-1141
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06785363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant