Provider Demographics
NPI:1457015703
Name:WILLIS, KELCIE RENAE (FNP-C)
Entity Type:Individual
Prefix:
First Name:KELCIE
Middle Name:RENAE
Last Name:WILLIS
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 1:302 MEDICAL PARK CT
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-4346
Mailing Address - Country:US
Mailing Address - Phone:252-247-2013
Mailing Address - Fax:252-247-7299
Practice Address - Street 1:302 MEDICAL PARK CT
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-4346
Practice Address - Country:US
Practice Address - Phone:252-247-2013
Practice Address - Fax:252-247-7299
Is Sole Proprietor?:No
Enumeration Date:2021-10-23
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNF10210943363LF0000X
NC5016172363LF0000X
TN249546163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse