Provider Demographics
NPI:1609853159
Name:LEVITAS, KELLY BRIANA (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:BRIANA
Last Name:LEVITAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:BRIANA
Other - Last Name:DIVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8821 BLAKENEY PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-6594
Mailing Address - Country:US
Mailing Address - Phone:704-887-1101
Mailing Address - Fax:704-887-1102
Practice Address - Street 1:8821 BLAKENEY PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6594
Practice Address - Country:US
Practice Address - Phone:704-887-1101
Practice Address - Fax:704-887-1102
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102908363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2751229BMedicare PIN
NCP41815Medicare UPIN