Provider Demographics
NPI:1922476266
Name:SHOEMAKER, KELLY ANN (NP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:SHOEMAKER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5112 N CROATAN HWY
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-3988
Mailing Address - Country:US
Mailing Address - Phone:252-449-7474
Mailing Address - Fax:
Practice Address - Street 1:5112 N CROATAN HWY
Practice Address - Street 2:
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-3988
Practice Address - Country:US
Practice Address - Phone:252-449-7474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5010406363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily