Provider Demographics
NPI:1720659469
Name:ALLIS, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ALLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:LEONARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:213 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549-2530
Mailing Address - Country:US
Mailing Address - Phone:252-412-6484
Mailing Address - Fax:
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4220
Practice Address - Country:US
Practice Address - Phone:984-974-1401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-04
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5014658363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5014658OtherNC BOARD OF NURSING