Provider Demographics
NPI:1982634762
Name:BENNETT, KELLY A (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 LEE ANN DR NE STE 200
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2915
Mailing Address - Country:US
Mailing Address - Phone:704-782-1892
Mailing Address - Fax:
Practice Address - Street 1:1028 LEE ANN DR NE STE 200
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2915
Practice Address - Country:US
Practice Address - Phone:704-782-1892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002137363AM0700X
NC0010-02297363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010201756Medicaid
VA010201683Medicaid
VA008637J76Medicare ID - Type Unspecified
VA010201756Medicaid