Provider Demographics
NPI:1942524418
Name:HAYMORE, KATHERINE BLACKMON (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:BLACKMON
Last Name:HAYMORE
Suffix:
Gender:F
Credentials:CPNP
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:167 MOORE RD STE 201
Practice Address - Street 2:
Practice Address - City:KING
Practice Address - State:NC
Practice Address - Zip Code:27021-8770
Practice Address - Country:US
Practice Address - Phone:336-673-6470
Practice Address - Fax:336-673-6489
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004664363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7005300Medicaid