Healthcare Provider Details

I. General information

NPI: 1912829706
Provider Name (Legal Business Name): AMANDA KATHRYN KABEALO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

4500 ASBURY PLACE DR
CLEMMONS NC
27012-7708
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-2011
  • Fax:
Mailing address:
  • Phone: 336-830-1913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number321292
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: