Provider Demographics
NPI:1447212378
Name:TATE, KELLY H (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:H
Last Name:TATE
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 1:199 E.B. TATE ROAD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217
Mailing Address - Country:US
Mailing Address - Phone:336-504-0538
Mailing Address - Fax:
Practice Address - Street 1:199 E.B. TATE ROAD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217
Practice Address - Country:US
Practice Address - Phone:336-504-0538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201324363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ36138Medicare UPIN
NC2592314Medicare PIN