Provider Demographics
NPI:1659309409
Name:KELLY, RITA HELEN (CNM)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:HELEN
Last Name:KELLY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1140 CARTHAGE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-4161
Mailing Address - Country:US
Mailing Address - Phone:919-775-2304
Mailing Address - Fax:919-775-4050
Practice Address - Street 1:1140 CARTHAGE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4161
Practice Address - Country:US
Practice Address - Phone:919-775-2304
Practice Address - Fax:919-775-4050
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC129367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000050Medicaid