Provider Demographics
NPI:1235473232
Name:KING, KELLI NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:NICOLE
Last Name:KING
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 FLORAL PKWY
Mailing Address - Street 2:UNIT 105
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6238
Mailing Address - Country:US
Mailing Address - Phone:910-799-6262
Mailing Address - Fax:910-799-6261
Practice Address - Street 1:1221 FLORAL PKWY
Practice Address - Street 2:UNIT 105
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6238
Practice Address - Country:US
Practice Address - Phone:910-799-6262
Practice Address - Fax:910-799-6261
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7006560Medicaid
NC7006560Medicaid