Provider Demographics
NPI:1497886956
Name:ACEVEDO, KELLY C (RN, MSN, GNP)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:C
Last Name:ACEVEDO
Suffix:
Gender:F
Credentials:RN, MSN, GNP
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:704-512-5363
Mailing Address - Fax:704-512-2428
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-512-5363
Practice Address - Fax:704-512-2428
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2854163WG0600X, 363LG0600X
NC249757363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7005508Medicaid
SCNP1093Medicaid
SCP00813613OtherRAILROAD MEDICARE ID-RSFPN
SCAA18755551Medicare PIN
SCAA18759223Medicare PIN
SCNP1093Medicaid