Healthcare Provider Details

I. General information

NPI: 1700161593
Provider Name (Legal Business Name): KIMBERLY QUAIL ATWOOD RD, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4419 BEN FRANKLIN BLVD
DURHAM NC
27704-2147
US

IV. Provider business mailing address

4419 BEN FRANKLIN BLVD
DURHAM NC
27704-2147
US

V. Phone/Fax

Practice location:
  • Phone: 919-477-3005
  • Fax: 919-477-5526
Mailing address:
  • Phone: 919-477-3005
  • Fax: 919-477-5526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL003725
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-07545
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: