Healthcare Provider Details

I. General information

NPI: 1073620076
Provider Name (Legal Business Name): KIMBERLY LYNN FERENCE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY MCCRITE

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114C MEMORIAL DR FAMILY CARE CLINIC P.A.
JACKSONVILLE NC
28546-6328
US

IV. Provider business mailing address

135 TIDEWATER DR
NEWPORT NC
28570
US

V. Phone/Fax

Practice location:
  • Phone: 910-353-9688
  • Fax: 910-353-7498
Mailing address:
  • Phone: 910-381-4834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103754
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: