Provider Demographics
NPI:1144635376
Name:GLISSON, KELLY LEE (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEE
Last Name:GLISSON
Suffix:
Gender:F
Credentials:NP
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 751069
Mailing Address - Street 2:ECU PHYSICIANS
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2421 SILVER STREAM LN
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7684
Practice Address - Country:US
Practice Address - Phone:910-341-3300
Practice Address - Fax:910-251-2067
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC229280363LF0000X
NC5006909363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC188F4OtherBCBSNC
NC1144635376Medicaid
NCNCK3440Medicare PIN