Healthcare Provider Details

I. General information

NPI: 1881014298
Provider Name (Legal Business Name): SHANNON BIVENS KINLAW M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 OAKMONT DR
GREENVILLE NC
27858-5936
US

IV. Provider business mailing address

118 OAKMONT DR
GREENVILLE NC
27858-5936
US

V. Phone/Fax

Practice location:
  • Phone: 252-364-8790
  • Fax: 252-364-8794
Mailing address:
  • Phone: 252-364-8790
  • Fax: 252-364-8794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number201666
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: