Provider Demographics
NPI:1518253251
Name:KELLY, TINA MARIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:KELLY
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 1:1300 BAXTER ST
Mailing Address - Street 2:STE 215
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3053
Mailing Address - Country:US
Mailing Address - Phone:704-332-0396
Mailing Address - Fax:704-971-0035
Practice Address - Street 1:433 COPPERFIELD BLVD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2405
Practice Address - Country:US
Practice Address - Phone:704-786-7770
Practice Address - Fax:704-971-0035
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17538363L00000X
NC5005521363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7006561Medicaid
NCNCB645BMedicare PIN