Healthcare Provider Details

I. General information

NPI: 1225922636
Provider Name (Legal Business Name): KYLIE JENNIFER LITTLETON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 NORTHLINE AVE #103
GREENSBORO NC
27408
US

IV. Provider business mailing address

737 E MAPLE LN
FUQUAY VARINA NC
27526-5125
US

V. Phone/Fax

Practice location:
  • Phone: 336-286-6565
  • Fax:
Mailing address:
  • Phone: 410-562-8001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-15816
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: