Provider Demographics
NPI:1346788056
Name:ECKENROTH, KIM (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:ECKENROTH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6045 PETERS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-4029
Mailing Address - Country:US
Mailing Address - Phone:540-989-6265
Mailing Address - Fax:540-989-1547
Practice Address - Street 1:6045 PETERS CREEK RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-4029
Practice Address - Country:US
Practice Address - Phone:540-989-6265
Practice Address - Fax:540-989-1547
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174481363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily