Healthcare Provider Details

I. General information

NPI: 1700984366
Provider Name (Legal Business Name): KIMBERLEY LIS BARRACCO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 KANAWHA TER
SAINT ALBANS WV
25177-2750
US

IV. Provider business mailing address

PO BOX 2168
SPARTANBURG SC
29304-2168
US

V. Phone/Fax

Practice location:
  • Phone: 304-757-6999
  • Fax:
Mailing address:
  • Phone: 864-560-4304
  • Fax: 864-560-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number39076
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2064
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: