Provider Demographics
NPI:1467486092
Name:KELLY, AMY SUE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SUE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 HOLDEN BEACH ROAD
Mailing Address - Street 2:
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-4096
Mailing Address - Country:US
Mailing Address - Phone:910-842-5991
Mailing Address - Fax:
Practice Address - Street 1:2930 HOLDEN BEACH RD SW
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-5702
Practice Address - Country:US
Practice Address - Phone:910-842-5991
Practice Address - Fax:910-842-5994
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102882363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS93044Medicare UPIN