Provider Demographics
NPI:1508279043
Name:TRULL, KELSEY NORKETT (PA)
Entity Type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:NORKETT
Last Name:TRULL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:KELSEY
Other - Middle Name:JEAN
Other - Last Name:NORKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4228 SAINT AUDREY PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-8394
Mailing Address - Country:US
Mailing Address - Phone:704-773-1488
Mailing Address - Fax:
Practice Address - Street 1:1070 VINEHAVEN DR NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2438
Practice Address - Country:US
Practice Address - Phone:704-783-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1508279043Medicaid
NC188GMOtherBCBS OF NORTH CAROLINA