Provider Demographics
NPI:1760906184
Name:EZZELL, KELLY GRANT (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:GRANT
Last Name:EZZELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 DOCK ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-4936
Mailing Address - Country:US
Mailing Address - Phone:910-254-9898
Mailing Address - Fax:
Practice Address - Street 1:1501 DOCK ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4936
Practice Address - Country:US
Practice Address - Phone:910-254-9898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP93846382088P0231X, 363L00000X
NC319192363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022054500Medicaid