Healthcare Provider Details

I. General information

NPI: 1699747329
Provider Name (Legal Business Name): KENNY DEWAYNE HEFNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 W PARK DR
N WILKESBORO NC
28659-3564
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-651-2980
  • Fax: 336-667-2047
Mailing address:
  • Phone: 336-651-2980
  • Fax: 336-667-2047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number97-00276
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number97-00276
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: