Provider Demographics
NPI:1881194223
Name:CORREA, KIMBERLY (FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CORREA
Suffix:
Gender:F
Credentials:FNP
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 1:704 GOLD HILL RD
Practice Address - Street 2:STE 1200
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-8906
Practice Address - Country:US
Practice Address - Phone:704-667-3380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21673363LF0000X
OHAPRN.CNP.0033005363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP5079Medicaid