Provider Demographics
NPI:1346430691
Name:MASON, KELLY CASSEDY (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CASSEDY
Last Name:MASON
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 1:176 BLUEBERRY LN
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-8328
Mailing Address - Country:US
Mailing Address - Phone:404-247-3168
Mailing Address - Fax:
Practice Address - Street 1:2645 MERIDIAN PKWY STE 323
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-4232
Practice Address - Country:US
Practice Address - Phone:984-227-8902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA124340163W00000X, 363LF0000X
NC5008052363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA005599973AMedicaid