Provider Demographics
NPI:1760045272
Name:POOR, SAVANNAH KELLY
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:KELLY
Last Name:POOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:910-721-4370
Mailing Address - Fax:
Practice Address - Street 1:6 DOCTORS CIR STE 5
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-6358
Practice Address - Country:US
Practice Address - Phone:910-721-4370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-19
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112197363AS0400X
NC0010-13123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical