Provider Demographics
NPI:1801091343
Name:NGUYEN, KELLY PATE (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:PATE
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:PATE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:1110 SE CARY PKWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-7420
Mailing Address - Country:US
Mailing Address - Phone:919-463-1101
Mailing Address - Fax:919-463-1110
Practice Address - Street 1:1110 SE CARY PKWY
Practice Address - Street 2:SUITE 206
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7420
Practice Address - Country:US
Practice Address - Phone:919-463-1101
Practice Address - Fax:919-463-1110
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201652363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003970Medicaid
NC2594181Medicare PIN
NC7003970Medicaid