Provider Demographics
NPI:1740785799
Name:SMITH-KIRBY, SANDRA DOREEN (AGNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:DOREEN
Last Name:SMITH-KIRBY
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3504 LANGSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-9314
Mailing Address - Country:US
Mailing Address - Phone:252-258-2370
Mailing Address - Fax:252-752-8555
Practice Address - Street 1:3504 LANGSTON BLVD
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-9314
Practice Address - Country:US
Practice Address - Phone:252-258-2370
Practice Address - Fax:252-752-8555
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5010887207Q00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty