Provider Demographics
NPI:1104135979
Name:KELLY, ANDREA W (RN, BSN)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:W
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1894
Mailing Address - Country:US
Mailing Address - Phone:704-939-1118
Mailing Address - Fax:
Practice Address - Street 1:704 OLD LILESVILLE ROAD
Practice Address - Street 2:
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170-2820
Practice Address - Country:US
Practice Address - Phone:704-694-6588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC111797163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse