Healthcare Provider Details

I. General information

NPI: 1508976432
Provider Name (Legal Business Name): KINSTON DERMATOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 DOCTORS DR KINSTON CLINIC NORTH, SUITE F
KINSTON NC
28501-1584
US

IV. Provider business mailing address

701 DOCTORS DR KINSTON CLINIC NORTH, SUITE F
KINSTON NC
28501-1584
US

V. Phone/Fax

Practice location:
  • Phone: 252-523-3289
  • Fax: 252-523-1310
Mailing address:
  • Phone: 252-523-3289
  • Fax: 252-523-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number84026
License Number StateNC

VIII. Authorized Official

Name: DR. DIANA MONROE HENSHAW
Title or Position: SECRETARY/TREASURER
Credential: EDD
Phone: 252-523-3289