Basic Information
Provider Information | |||||||||
NPI: | 1174577092 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEVY | ||||||||
FirstName: | KATHY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | GNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CUNDIFF | ||||||||
OtherFirstName: | KATHY | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3069 TRENWEST DR | ||||||||
Address2: | STE 200 | ||||||||
City: | WINSTON SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271033211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3369933146 | ||||||||
FaxNumber: | 3369923930 | ||||||||
Practice Location | |||||||||
Address1: | 3069 TRENWEST DR | ||||||||
Address2: | STE 200 | ||||||||
City: | WINSTON SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271033211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3369933146 | ||||||||
FaxNumber: | 3369923930 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2006 | ||||||||
LastUpdateDate: | 05/19/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 52729 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LG0600X | 600128 | NC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
ID | Type | State | Issuer | Description | ML0809600 | 01 | NC | DEA | OTHER | 600128 | 01 | NC | MED LIC | OTHER | 1855N | 01 | NC | BCBS | OTHER |