Provider Demographics
NPI:1194011007
Name:BURRIS, KELLY RUSSELL (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RUSSELL
Last Name:BURRIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MICHELE
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:LAUREL FORK
Mailing Address - State:VA
Mailing Address - Zip Code:24352-0009
Mailing Address - Country:US
Mailing Address - Phone:276-398-1200
Mailing Address - Fax:336-789-0856
Practice Address - Street 1:109 CARROLL DRIVE
Practice Address - Street 2:
Practice Address - City:FRIES
Practice Address - State:VA
Practice Address - Zip Code:24330-4532
Practice Address - Country:US
Practice Address - Phone:888-908-4788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007750363L00000X, 363LF0000X
VA0024169439363L00000X
VA0021469439363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner