Provider Demographics
NPI:1598151177
Name:KELLY, ALLIE BLACK (PAC)
Entity Type:Individual
Prefix:
First Name:ALLIE
Middle Name:BLACK
Last Name:KELLY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ALLIE
Other - Middle Name:DUKE
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4601 PARK ROAD
Mailing Address - Street 2:STE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209
Mailing Address - Country:US
Mailing Address - Phone:704-323-2000
Mailing Address - Fax:
Practice Address - Street 1:2001 VAIL AVE STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1222
Practice Address - Country:US
Practice Address - Phone:704-323-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108675363A00000X
SC2733363A00000X
NC0010-05675363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2733OtherMEDICAL LICENSE
NC0010-05675OtherMEDICAL LICENSE
NC1598151177Medicaid