Provider Demographics
NPI:1952016560
Name:BAUCOM, KIMBERLEY M
Entity Type:Individual
Prefix:MS
First Name:KIMBERLEY
Middle Name:M
Last Name:BAUCOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6834 MELODY LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-7786
Mailing Address - Country:US
Mailing Address - Phone:704-712-9856
Mailing Address - Fax:
Practice Address - Street 1:6834 MELODY LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-7786
Practice Address - Country:US
Practice Address - Phone:704-712-9856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 374J00000X
NC374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoula
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty