Provider Demographics
NPI:1215412465
Name:KEMAK, KELLY (LCGC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KEMAK
Suffix:
Gender:F
Credentials:LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:980-302-6270
Mailing Address - Fax:980-302-6275
Practice Address - Street 1:125 QUEENS RD STE 560
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3215
Practice Address - Country:US
Practice Address - Phone:980-302-6270
Practice Address - Fax:980-302-6275
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECG-0000193170300000X
NC170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS