Provider Demographics
NPI:1891858668
Name:KELLY, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:KELLY
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 1:205 SAGE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-6995
Mailing Address - Country:US
Mailing Address - Phone:919-942-4173
Mailing Address - Fax:919-933-3473
Practice Address - Street 1:205 SAGE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-6995
Practice Address - Country:US
Practice Address - Phone:919-942-4173
Practice Address - Fax:919-933-3473
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC300170208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare ID - Type Unspecified