Provider Demographics
NPI:1881900595
Name:ST. GEORGE, KELLY B (FNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:B
Last Name:ST. GEORGE
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10620 PARK RD
Practice Address - Street 2:STE 202
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8472
Practice Address - Country:US
Practice Address - Phone:704-667-0920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004843363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1881900595Medicaid
NCNC5724BMedicare PIN
NCNC5724FMedicare PIN
NCNC5724A968Medicare Oscar/Certification
NCNC5724DMedicare PIN
NC2594921Medicare PIN
NC1881900595Medicaid
NCNC5724CMedicare PIN
NCNC5724AMedicare PIN