=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790734945
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN MICHELLE FLOCKE MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2006
-----------------------------------------------------
Last Update Date | 01/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2817 ROCK MERRITT AVE
-----------------------------------------------------
City | FORT LIBERTY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28310-4603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-907-6823
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 256 ROLLING PINES DR
-----------------------------------------------------
City | SPRING LAKE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28390-7057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-303-4424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 23884
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------