Provider Demographics
NPI:1548817000
Name:REA, KELSEY LAURA (PA-C)
Entity type:Individual
Prefix:MISS
First Name:KELSEY
Middle Name:LAURA
Last Name:REA
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 1:531 EVOLVE DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-4693
Mailing Address - Country:US
Mailing Address - Phone:910-986-0155
Mailing Address - Fax:
Practice Address - Street 1:2601 LAKE DR STE 201
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6689
Practice Address - Country:US
Practice Address - Phone:919-783-4888
Practice Address - Fax:919-783-4887
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09357363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant