Provider Demographics
NPI:1700049079
Name:LAWRENCE, KELLEY VANCE (MD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:VANCE
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19485 OLD JETTON RD STE 100
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6583
Practice Address - Country:US
Practice Address - Phone:704-316-5170
Practice Address - Fax:704-316-5172
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA236981207Q00000X
NC2012-01448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine