Healthcare Provider Details

I. General information

NPI: 1548529050
Provider Name (Legal Business Name): TINA LOUISE KINNEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 E BROAD ST
STATESVILLE NC
28625-4302
US

IV. Provider business mailing address

1540 E BROAD ST
STATESVILLE NC
28625-4302
US

V. Phone/Fax

Practice location:
  • Phone: 704-360-6500
  • Fax:
Mailing address:
  • Phone: 704-360-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2013041627
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number2010041916
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5012783
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: