Provider Demographics
NPI:1760777098
Name:KITCHEN, CONNIE P (FNPC, RN & PA)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:P
Last Name:KITCHEN
Suffix:
Gender:F
Credentials:FNPC, RN & PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546
Mailing Address - Country:US
Mailing Address - Phone:910-577-2770
Mailing Address - Fax:910-577-2766
Practice Address - Street 1:192 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546
Practice Address - Country:US
Practice Address - Phone:910-577-1400
Practice Address - Fax:910-577-2725
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200139363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8913388Medicaid
NC8913388Medicaid
NCF61333Medicare UPIN