Basic Information
| Provider Information | |||||||||
| NPI: | 1801917679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLAYTON | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 SMITH CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | ROANOKE RAPIDS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278704914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525358011 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 210 SMITH CHURCH ROAD | ||||||||
| Address2: | |||||||||
| City: | ROANOKE RAPIDS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278704914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525358011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 07/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C003950 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 163W00000X | C003950 | NC | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | C003950 | 01 | NC | STATE LICENSE NUMBER | OTHER |