Provider Demographics
NPI:1396957429
Name:VAN FOSSEN, KELLY MARIE (DO)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MARIE
Last Name:VAN FOSSEN
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:4140 FERNCREEK DRIVE
Mailing Address - Street 2:SUITE 601
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2569
Mailing Address - Country:US
Mailing Address - Phone:910-485-3880
Mailing Address - Fax:910-485-5341
Practice Address - Street 1:4140 FERNCREEK DRIVE
Practice Address - Street 2:SUITE 601
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2569
Practice Address - Country:US
Practice Address - Phone:910-485-3880
Practice Address - Fax:910-485-5341
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2014-06-03
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Provider Licenses
StateLicense IDTaxonomies
NC2009-00374208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery