Healthcare Provider Details

I. General information

NPI: 1578563235
Provider Name (Legal Business Name): KIMBERLY MALLICK FILLMAN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 HOSPITAL DR NE
BOLIVIA NC
28422-8346
US

IV. Provider business mailing address

240 HOSPITAL DR NE
BOLIVIA NC
28422-8346
US

V. Phone/Fax

Practice location:
  • Phone: 843-497-5929
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number101827
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number101827
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: