Provider Demographics
NPI:1154373579
Name:KELLY, LAURA HERRING (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:HERRING
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:LEE
Other - Last Name:HERRING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4414 LAKE BOONE TRAIL
Mailing Address - Street 2:SUITE 103
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607
Mailing Address - Country:US
Mailing Address - Phone:919-787-0266
Mailing Address - Fax:919-571-9314
Practice Address - Street 1:4414 LAKE BOONE TRAIL
Practice Address - Street 2:SUITE 103
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607
Practice Address - Country:US
Practice Address - Phone:919-787-0266
Practice Address - Fax:919-571-9314
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701433208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC012U3OtherBCBS
NC79012U3Medicaid
NC79012U3Medicaid