Provider Demographics
NPI:1407642317
Name:STOCUM, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:STOCUM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:CHARLIE
Other - Middle Name:
Other - Last Name:STOCUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 44308
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-0047
Mailing Address - Country:US
Mailing Address - Phone:704-372-9393
Mailing Address - Fax:
Practice Address - Street 1:4651 CHARLOTTE PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-3037
Practice Address - Country:US
Practice Address - Phone:704-461-0006
Practice Address - Fax:704-461-0006
Is Sole Proprietor?:No
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1413172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker