Provider Demographics
NPI:1548746365
Name:BRINO, KASSONDRA AMADA SHOEMAKER (RN, CPNP-PC)
Entity Type:Individual
Prefix:
First Name:KASSONDRA
Middle Name:AMADA SHOEMAKER
Last Name:BRINO
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Gender:F
Credentials:RN, CPNP-PC
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Mailing Address - Street 1:210 SILVER PINE CT
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-9266
Mailing Address - Country:US
Mailing Address - Phone:919-627-8771
Mailing Address - Fax:
Practice Address - Street 1:307 S SALEM ST STE 100
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-1845
Practice Address - Country:US
Practice Address - Phone:919-627-8771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-15
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC50106932080P0006X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC68535Medicaid