Provider Demographics
NPI:1972843969
Name:CAPOBIANCO, KELLY L (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:CAPOBIANCO
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 1:2421 SILVER STREAM LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7684
Mailing Address - Country:US
Mailing Address - Phone:910-341-3300
Mailing Address - Fax:910-251-2067
Practice Address - Street 1:2421 SILVER STREAM LN
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7684
Practice Address - Country:US
Practice Address - Phone:910-341-3300
Practice Address - Fax:910-251-2067
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006062363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics