Provider Demographics
NPI:1396376380
Name:CONWAY, KELLY JEANNE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEANNE
Last Name:CONWAY
Suffix:
Gender:F
Credentials:FNP-C
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 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:5085 MORGANTON RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-1523
Practice Address - Country:US
Practice Address - Phone:910-323-3890
Practice Address - Fax:910-323-4509
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012788363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNNB501AOtherMEDICARE PTAN
NC1396376380Medicaid
NCNNB501BOtherMEDICARE PTAN