Healthcare Provider Details

I. General information

NPI: 1760777098
Provider Name (Legal Business Name): CONNIE P KITCHEN FNPC, RN & PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 VILLAGE DR
JACKSONVILLE NC
28546
US

IV. Provider business mailing address

192 VILLAGE DR
JACKSONVILLE NC
28546
US

V. Phone/Fax

Practice location:
  • Phone: 910-577-1400
  • Fax: 910-577-2725
Mailing address:
  • Phone: 910-577-2770
  • Fax: 910-577-2766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number200139
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: