Provider Demographics
NPI:1437731353
Name:ZACCARIA, KYLIE LYNN (PA)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:LYNN
Last Name:ZACCARIA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 FAIRGROVE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-9617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:607-753-6677
Practice Address - Street 1:810 FAIRGROVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-9617
Practice Address - Country:US
Practice Address - Phone:828-326-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06743026Medicaid