Healthcare Provider Details

I. General information

NPI: 1003395948
Provider Name (Legal Business Name): KAILA HASKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2018
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 FRONTIS PLAZA BLVD
WINSTON SALEM NC
27103-5614
US

IV. Provider business mailing address

PO BOX 604042
CHARLOTTE NC
28260-4042
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-4136
  • Fax: 704-417-4814
Mailing address:
  • Phone: 704-316-4136
  • Fax: 704-417-4814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5011512
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024176493
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5011512
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: