Provider Demographics
NPI:1700886595
Name:COLLIER, KELLY (PA)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:
Last Name:COLLIER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:615 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6431
Mailing Address - Country:US
Mailing Address - Phone:102-025-7099
Mailing Address - Fax:910-202-9966
Practice Address - Street 1:120 COASTAL HORIZONS DR
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-6094
Practice Address - Country:US
Practice Address - Phone:910-754-4515
Practice Address - Fax:910-202-9966
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC103680363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2757719Medicare ID - Type UnspecifiedPROVIDER NUMBER
NCP83177Medicare UPIN