Provider Demographics
NPI:1942612890
Name:SMITH, KIMBERLEY (NP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLEY
Middle Name:
Last Name:SMITH
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 1:623 COUNTRY DAY RD
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-8888
Mailing Address - Country:US
Mailing Address - Phone:919-330-1940
Mailing Address - Fax:
Practice Address - Street 1:623 COUNTRY DAY RD
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-8888
Practice Address - Country:US
Practice Address - Phone:919-330-1940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-27
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007058363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMM3255862OtherDEA
NC5007058OtherNP LICENSE