Provider Demographics
NPI:1760865083
Name:KELLY, MELISSA MARIE (PA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
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 1:6331 CARMEL RD STE 102
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8286
Practice Address - Country:US
Practice Address - Phone:704-316-9022
Practice Address - Fax:704-316-9026
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2965363AM0700X
NY019004363AM0700X
NC0010-08075363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical