Healthcare Provider Details

I. General information

NPI: 1366797128
Provider Name (Legal Business Name): MARY KATHLEEN BOONE PERRY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 ACADEMY ST S
AHOSKIE NC
27910-3264
US

IV. Provider business mailing address

700 ACADEMY ST S
AHOSKIE NC
27910-3264
US

V. Phone/Fax

Practice location:
  • Phone: 252-209-3867
  • Fax: 252-209-3490
Mailing address:
  • Phone: 252-209-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number225340
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: