Provider Demographics
NPI:1760507958
Name:CARPENTER, KELLY BERGERON (NP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:BERGERON
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:NP-C
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-210-5260
Mailing Address - Fax:704-210-5265
Practice Address - Street 1:612 MOCKSVILLE AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2732
Practice Address - Country:US
Practice Address - Phone:704-210-5260
Practice Address - Fax:704-210-5265
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5002933363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1760507958Medicaid
NC182E4OtherBCBS
NCNCE536BOtherMEDICARE
NCP02479422OtherRAILROAD MEDICARE