1588838320 NPI number — MISS COREY ELYSSE KILCULLEN M.A.

Table of content: MISS COREY ELYSSE KILCULLEN M.A. (NPI 1588838320)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588838320 NPI number — MISS COREY ELYSSE KILCULLEN M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILCULLEN
Provider First Name:
COREY
Provider Middle Name:
ELYSSE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588838320
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1817 EWING AVE
Provider Second Line Business Mailing Address:
APT. B
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28203-5739
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-403-6210
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7110 BRIGHTON PARK DR
Provider Second Line Business Practice Location Address:
SUITE 400 PMB 168
Provider Business Practice Location Address City Name:
MINT HILL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28227-7987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-965-0783
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  8035 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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