1699788372 NPI number — MRS. KIMBERLY S WILLIAMSON CPO, CFM

Table of content: MRS. KIMBERLY S WILLIAMSON CPO, CFM (NPI 1699788372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699788372 NPI number — MRS. KIMBERLY S WILLIAMSON CPO, CFM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMSON
Provider First Name:
KIMBERLY
Provider Middle Name:
S
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CPO, CFM
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:
1699788372
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 MEDICAL DRIVE
Provider Second Line Business Mailing Address:
PO BOX 1471
Provider Business Mailing Address City Name:
ELIZ CITY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-338-3002
Provider Business Mailing Address Fax Number:
252-338-2902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 MEDICAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZ CITY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-338-3002
Provider Business Practice Location Address Fax Number:
252-338-2902
Provider Enumeration Date:
08/14/2006

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: 222Z00000X , with the licence number:  CPO03814 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224P00000X , with the licence number: CPO03814 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BC3200X , 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)

  • Identifier: 0482P . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 9190511 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 384410 . This is a "BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7701327 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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