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General NPI Number Information
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NPI Number | 1700984366
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Entity Type | Individual
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Provider Name | KIMBERLEY LIS BARRACCO DO
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Gender | Female
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 09/18/2023
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Provider Practice Location Address
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Address Line | 12 KANAWHA TER
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City | SAINT ALBANS
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State | WV
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Zip | 25177-2750
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Country | US
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Telephone | 304-757-6999
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2168
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City | SPARTANBURG
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State | SC
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Zip | 29304-2168
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Country | US
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Telephone | 864-560-4304
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Fax | 864-560-4413
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 39076
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 2064
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License Number State | WV
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