Provider Demographics
NPI:1699752717
Name:THOMPSON-BRAZILL, KELLY A (ACNP)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:THOMPSON-BRAZILL
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3208 ENCHANTING WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-8372
Mailing Address - Country:US
Mailing Address - Phone:919-752-0153
Mailing Address - Fax:
Practice Address - Street 1:2100 STANTONSBURG RD
Practice Address - Street 2:TRAUMA & SURGICAL CRITICAL CARE, 2ND FLOOR ED TOWER
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2818
Practice Address - Country:US
Practice Address - Phone:252-847-4299
Practice Address - Fax:252-847-8208
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC960051363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003697Medicaid
NC2592243Medicare ID - Type Unspecified
NC7003697Medicaid