Provider Demographics
NPI:1558324152
Name:BOONE, KELLY ANN (FNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:BOONE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 SIGNAL HILL DRIVE EXT
Mailing Address - Street 2:PO BOX 1845
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4353
Mailing Address - Country:US
Mailing Address - Phone:704-873-4277
Mailing Address - Fax:
Practice Address - Street 1:700 SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3440
Practice Address - Country:US
Practice Address - Phone:704-924-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201078363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS93502Medicare UPIN
NC2599085Medicare ID - Type Unspecified