Healthcare Provider Details

I. General information

NPI: 1194549907
Provider Name (Legal Business Name): KATHY VANNACHITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2024
Last Update Date: 11/09/2024
Certification Date: 11/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 TRENT DR
DURHAM NC
27710-3038
US

IV. Provider business mailing address

307 TRENT DR
DURHAM NC
27710-3038
US

V. Phone/Fax

Practice location:
  • Phone: 919-684-4248
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2023061514
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: