Healthcare Provider Details

I. General information

NPI: 1619554458
Provider Name (Legal Business Name): KRISTAL DOUB CARROLL WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

6750 FISHER RD
TOBACCOVILLE NC
27050-9746
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-4039
  • Fax:
Mailing address:
  • Phone: 928-503-9488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberCARR-YPY06
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5014318
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: