Healthcare Provider Details

I. General information

NPI: 1770573370
Provider Name (Legal Business Name): MS. CHARLENE Y KIRBY
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 JABARRAH AVE SEYMOUR JOHNSON AFB
GOLDSBORO NC
27531-2310
US

IV. Provider business mailing address

1050 JABARRAH AVE SEYMOUR JOHNSON AFB
GOLDSBORO NC
27531-2310
US

V. Phone/Fax

Practice location:
  • Phone: 919-722-0928
  • Fax: 919-722-1952
Mailing address:
  • Phone: 919-722-0928
  • Fax: 919-722-1952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: