Provider Demographics
NPI:1386909414
Name:HAMMOUDI, KELLY BILELLO (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:BILELLO
Last Name:HAMMOUDI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1830 S HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4014
Mailing Address - Country:US
Mailing Address - Phone:336-448-2427
Mailing Address - Fax:336-765-2869
Practice Address - Street 1:1901 S HAWTHORNE RD STE 310
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3915
Practice Address - Country:US
Practice Address - Phone:336-448-2427
Practice Address - Fax:336-765-2869
Is Sole Proprietor?:No
Enumeration Date:2012-07-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC222051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC952573016Medicaid