Healthcare Provider Details

I. General information

NPI: 1265411086
Provider Name (Legal Business Name): KENNETH KYLE CLONINGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 SCHENCK ST
SHELBY NC
28150-3934
US

IV. Provider business mailing address

808 SCHENCK ST CLECO PRIMARY CARE NETWORK
SHELBY NC
28150-3934
US

V. Phone/Fax

Practice location:
  • Phone: 704-480-9344
  • Fax: 704-484-3260
Mailing address:
  • Phone: 704-480-9344
  • Fax: 704-484-3260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9500537
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: