Provider Demographics
NPI:1467924514
Name:MCLANE, KELLI ANN (PA-C)
Entity type:Individual
Prefix:MISS
First Name:KELLI
Middle Name:ANN
Last Name:MCLANE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:146 MEDICAL PARK RD STE 212
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8529
Mailing Address - Country:US
Mailing Address - Phone:704-659-7850
Mailing Address - Fax:877-881-8455
Practice Address - Street 1:9930 KINCEY AVE STE 165
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-6541
Practice Address - Country:US
Practice Address - Phone:704-947-5005
Practice Address - Fax:877-881-8455
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-09920363A00000X
VA0110006493363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0397730024OtherNSC#