Provider Demographics
NPI:1972072114
Name:CAROLLO, KIM MARION (NP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARION
Last Name:CAROLLO
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 1:179 N HARBOR WATCH DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-2483
Mailing Address - Country:US
Mailing Address - Phone:516-316-5392
Mailing Address - Fax:516-316-5392
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:CMC ANNEX, 1ST FLOOR
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203
Practice Address - Country:US
Practice Address - Phone:704-355-0270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23520363LA2100X
GARN282977363LA2100X
NC5012470363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP64661Medicaid