Basic Information
| Provider Information | |||||||||
| NPI: | 1083954689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLS | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | FAYE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOEHN | ||||||||
| OtherFirstName: | KATHY | ||||||||
| OtherMiddleName: | FAYE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 550 GLENWOOD DR | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281152876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046647494 | ||||||||
| FaxNumber: | 7046648454 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 GLENWOOD DR | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281152876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046647494 | ||||||||
| FaxNumber: | 7046648454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2013 | ||||||||
| LastUpdateDate: | 08/21/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5005988 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1083954689 | 05 | NC | MEDICAID |