Healthcare Provider Details

I. General information

NPI: 1639066046
Provider Name (Legal Business Name): CARMELA KIM GONZALES TIERNEY-HESTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 WHITE RD
KING NC
27021-9526
US

IV. Provider business mailing address

5637 GLAD ACRES RD
PFAFFTOWN NC
27040-9288
US

V. Phone/Fax

Practice location:
  • Phone: 336-983-6505
  • Fax:
Mailing address:
  • Phone: 619-228-1215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number5025322
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5025322
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: