Basic Information
| Provider Information | |||||||||
| NPI: | 1760777098 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KITCHEN | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNPC, RN & PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 192 VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105772770 | ||||||||
| FaxNumber: | 9105772766 | ||||||||
| Practice Location | |||||||||
| Address1: | 192 VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105771400 | ||||||||
| FaxNumber: | 9105772725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2011 | ||||||||
| LastUpdateDate: | 06/15/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 200139 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 8913388 | 05 | NC | MEDICAID |