Healthcare Provider Details

I. General information

NPI: 1245322981
Provider Name (Legal Business Name): HOLLY DEMAREST KOCKLER RN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 N. ROAD ST., STE K CAROLINA COASTAL PLASTIC SURGERY
ELIZABETH CITY NC
27909
US

IV. Provider business mailing address

1141 N. ROAD ST., STE K CAROLINA COASTAL PLASTIC SURGERY
ELIZABETH CITY NC
27909
US

V. Phone/Fax

Practice location:
  • Phone: 252-335-2293
  • Fax: 252-331-2387
Mailing address:
  • Phone: 252-335-2293
  • Fax: 252-331-2387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number082463
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200736
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: