Provider Demographics
NPI:1861020612
Name:KELLY, KRYSTLE (NP)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3803 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-2593
Mailing Address - Country:US
Mailing Address - Phone:336-941-1123
Mailing Address - Fax:844-237-5916
Practice Address - Street 1:3803 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2593
Practice Address - Country:US
Practice Address - Phone:336-941-1123
Practice Address - Fax:844-237-5916
Is Sole Proprietor?:No
Enumeration Date:2020-03-28
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC246966363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily