Provider Demographics
NPI:1184328809
Name:DAVIS, KELLY KIMBLE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:KIMBLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:KIMBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:604 E RAINTREE LN
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-8225
Mailing Address - Country:US
Mailing Address - Phone:919-222-3277
Mailing Address - Fax:
Practice Address - Street 1:604 E RAINTREE LN
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-8225
Practice Address - Country:US
Practice Address - Phone:919-222-3277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program