Provider Demographics
NPI:1083954689
Name:MILLS, KATHY FAYE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:FAYE
Last Name:MILLS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:FAYE
Other - Last Name:KOEHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:550 GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2876
Mailing Address - Country:US
Mailing Address - Phone:704-664-7494
Mailing Address - Fax:704-664-8454
Practice Address - Street 1:550 GLENWOOD DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2876
Practice Address - Country:US
Practice Address - Phone:704-664-7494
Practice Address - Fax:704-664-8454
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-20
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005988363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1083954689Medicaid
NCNCC683BMedicare PIN
NCNCC683AMedicare PIN