MEDICARE: MRS. KIM ECKENROTH NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0024174481	VA

General Provider Information

NPI Number	:	1346788056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIM ECKENROTH NP-C

Provider Business Mailing Address
First Line	:	6045 PETERS CREEK RD
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24019-4029
Country	:	US
Telephone Number	:	540-989-6265
Fax Number	:	540-989-1547

Provider Business Practice Location Address
First Line	:	6045 PETERS CREEK RD
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24019-4029
Country	:	US
Telephone Number	:	540-989-6265
Fax Number	:	540-989-1547

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2017
Last Update Date	:	02/02/2017

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