Healthcare Provider Details

I. General information

NPI: 1760139323
Provider Name (Legal Business Name): COASTAL HEADACHE CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2022
Last Update Date: 09/17/2022
Certification Date: 09/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 COUNTRY CLUB RD STE B
JACKSONVILLE NC
28546-6042
US

IV. Provider business mailing address

1715 COUNTRY CLUB RD STE B
JACKSONVILLE NC
28546-6042
US

V. Phone/Fax

Practice location:
  • Phone: 910-238-2050
  • Fax:
Mailing address:
  • Phone: 910-238-2050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TERRA KAMP
Title or Position: PRESIDENT
Credential: FNP
Phone: 614-571-4245