Provider Demographics
NPI:1295764165
Name:JOHN, KELLY DEANNE (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DEANNE
Last Name:JOHN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 PROFESSIONAL PARK DR STE 150
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1307
Mailing Address - Country:US
Mailing Address - Phone:336-607-8061
Mailing Address - Fax:336-724-6123
Practice Address - Street 1:8936 BLAKENEY PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6660
Practice Address - Country:US
Practice Address - Phone:704-943-3714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101452363AM0700X
NC0010-12240363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP54469Medicare UPIN