Provider Demographics
NPI:1376682195
Name:ROSEBROCK, KELLEY ANN (FNP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:ANN
Last Name:ROSEBROCK
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:PO BOX 602148
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2148
Mailing Address - Country:US
Mailing Address - Phone:704-667-3380
Mailing Address - Fax:704-667-3381
Practice Address - Street 1:704 GOLD HILL RD
Practice Address - Street 2:SUITE 1200
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-8906
Practice Address - Country:US
Practice Address - Phone:704-667-3380
Practice Address - Fax:704-667-3381
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC212050363L00000X
NC0050-02423363LF0000X
SC19252363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1376682195Medicaid
NC7004104Medicaid
SCNP1197Medicaid
NC1376682195Medicaid
NCNCA410EMedicare PIN
NCNCA410FMedicare PIN
NCNCA410AMedicare PIN
NC2593163Medicare PIN
NCNCA410DMedicare PIN
NCNCA410CMedicare PIN
SCSC57877772Medicare PIN