Individual
ALLIE BLACK KELLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.C
Contact information
Practice address
2001 VAIL AVE STE 200, CHARLOTTE, NC 28207-1222
(704) 323-2000
Mailing address
4601 PARK ROAD, STE 300, CHARLOTTE, NC 28209
(704) 323-2000
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0010-05675
NC
363A00000X
Physician Assistant
2733
SC
363A00000X
Physician Assistant
PA9108675
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0010-05675
MEDICAL LICENSE
NC
05
—
1598151177
—
NC
01
—
2733
MEDICAL LICENSE
SC
Enumeration date
04/10/2015
Last updated
06/13/2018
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