=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932835410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KATRINA T SIDNEY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2022
-----------------------------------------------------
Last Update Date | 05/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 712 WILKINS ST STE E
-----------------------------------------------------
City | SMITHFIELD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27577-4664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-390-1677
-----------------------------------------------------
Fax | 919-238-7974
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1425 S POLLOCK ST # 177
-----------------------------------------------------
City | SELMA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27576-3405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-390-1677
-----------------------------------------------------
Fax | 919-238-7974
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KATRINA T SIDNEY
-----------------------------------------------------
Credential | FNP-C
-----------------------------------------------------
Telephone | 919-879-9230
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------