Healthcare Provider Details

I. General information

NPI: 1518588409
Provider Name (Legal Business Name): KRISTIN LEIGH DANIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 KIMEL PARK DR STE 155
WINSTON SALEM NC
27103-6946
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-6637
  • Fax: 336-765-6964
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number245798
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5014173
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: