Provider Demographics
NPI:1982634762
Name:BENNETT, KELLY A (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1845
Mailing Address - Country:US
Mailing Address - Phone:704-873-4277
Mailing Address - Fax:704-978-3549
Practice Address - Street 1:700 SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3440
Practice Address - Country:US
Practice Address - Phone:704-924-9111
Practice Address - Fax:704-883-0452
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002137363AM0700X
NC0010-02297363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010201683Medicaid
VA010201756Medicaid
VA008637J76Medicare ID - Type Unspecified
VA010201756Medicaid