Provider Demographics
NPI:1609223973
Name:KIVETT, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KIVETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 LITTLE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28312-6436
Mailing Address - Country:US
Mailing Address - Phone:910-224-1133
Mailing Address - Fax:
Practice Address - Street 1:1206 N FULTON ST
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-1926
Practice Address - Country:US
Practice Address - Phone:910-875-4280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC566172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker