Provider Demographics
NPI:1114560794
Name:KOONTZ, KIMBERLEY (PMHNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8604 ROYSTER RUN
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7831
Mailing Address - Country:US
Mailing Address - Phone:609-558-3888
Mailing Address - Fax:
Practice Address - Street 1:3303 LATROBE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4851
Practice Address - Country:US
Practice Address - Phone:704-362-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012464363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health