Provider Demographics
NPI:1962123265
Name:RYDELL, KELLY WILLIAMS (FNP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:WILLIAMS
Last Name:RYDELL
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LIANNE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1912 WEDGEDALE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-4544
Mailing Address - Country:US
Mailing Address - Phone:703-400-2551
Mailing Address - Fax:
Practice Address - Street 1:1740 HIGHWAY 160 W
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8025
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95021706363LF0000X
NC5016854363LF0000X
SC27403363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily