Provider Demographics
NPI:1487493912
Name:MCLEROY, KRISTEN BLANCHE TALTY (PA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:BLANCHE TALTY
Last Name:MCLEROY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:BLANCHE TALTY
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2330 WESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3643
Mailing Address - Country:US
Mailing Address - Phone:757-692-0257
Mailing Address - Fax:
Practice Address - Street 1:2020 N PEACE HAVEN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4851
Practice Address - Country:US
Practice Address - Phone:336-768-1280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-23
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-14512363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant