1740785799 NPI number — SANDRA DOREEN SMITH-KIRBY AGNP

Table of content: SANDRA DOREEN SMITH-KIRBY AGNP (NPI 1740785799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740785799 NPI number — SANDRA DOREEN SMITH-KIRBY AGNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH-KIRBY
Provider First Name:
SANDRA
Provider Middle Name:
DOREEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AGNP
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:
1740785799
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3504 LANGSTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTERVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28590-9314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-258-2370
Provider Business Mailing Address Fax Number:
252-752-8555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3504 LANGSTON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTERVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28590-9314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-258-2370
Provider Business Practice Location Address Fax Number:
252-752-8555
Provider Enumeration Date:
03/29/2018

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: 207Q00000X , with the licence number:  5010887 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , with the licence number: 5010887 , 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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