Healthcare Provider Details

I. General information

NPI: 1558951657
Provider Name (Legal Business Name): KIM MATTINGLY MSL, TSAC-F
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

985 BUFFALO LAKE RD
SANFORD NC
27332-2351
US

IV. Provider business mailing address

985 BUFFALO LAKE RD
SANFORD NC
27332-2351
US

V. Phone/Fax

Practice location:
  • Phone: 910-578-4180
  • Fax:
Mailing address:
  • Phone: 910-578-4180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number001000656
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: