Basic Information
Provider Information | |||||||||
NPI: | 1982661450 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOULINEAU | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: | SHEETS | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SHEETS | ||||||||
OtherFirstName: | KATHRYN | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 751069 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282751069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 101 HEART DR | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 278348982 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2527444611 | ||||||||
FaxNumber: | 2527443201 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2006 | ||||||||
LastUpdateDate: | 12/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 0010-00317 | NC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 0010-00317 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1982661450 | 05 | NC |   | MEDICAID | 189TE | 01 | NC | BCBS OF NC | OTHER |