Healthcare Provider Details

I. General information

NPI: 1477511608
Provider Name (Legal Business Name): CATHERINE S KITTRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114A MEMORIAL DR
JACKSONVILLE NC
28546-6328
US

IV. Provider business mailing address

PO BOX 986513 DEPARTMENT 100
BOSTON MA
02298-6513
US

V. Phone/Fax

Practice location:
  • Phone: 910-353-0700
  • Fax: 910-353-5305
Mailing address:
  • Phone: 910-219-8310
  • Fax: 910-939-4269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103686
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: