Provider Demographics
NPI:1841604667
Name:KLOEFKORN, KYMBERLY (NP)
Entity Type:Individual
Prefix:
First Name:KYMBERLY
Middle Name:
Last Name:KLOEFKORN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 ABBEY PL
Practice Address - Street 2:BUILDING 2 SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3835
Practice Address - Country:US
Practice Address - Phone:704-512-2980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006958363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2855Medicaid
NC1841604667Medicaid
NCNCJ408BMedicare PIN