Provider Demographics
NPI:1114465531
Name:MINTZ, KACIE (FNP-C, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:KACIE
Middle Name:
Last Name:MINTZ
Suffix:
Gender:F
Credentials:FNP-C, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 WESTOVER DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3646
Mailing Address - Country:US
Mailing Address - Phone:336-816-9701
Mailing Address - Fax:
Practice Address - Street 1:50 MILLER ST
Practice Address - Street 2:SUITE G
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4205
Practice Address - Country:US
Practice Address - Phone:336-718-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC231237363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner