Provider Demographics
NPI:1871735068
Name:SQUIRES, KIMBERLY S (FNP-C; PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:FNP-C; PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10320 MALLARD CREEK RD
Mailing Address - Street 2:STE 240
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-9756
Mailing Address - Country:US
Mailing Address - Phone:704-886-8703
Mailing Address - Fax:
Practice Address - Street 1:10320 MALLARD CREEK RD
Practice Address - Street 2:STE 240
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-9756
Practice Address - Country:US
Practice Address - Phone:704-886-8703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008001301363LF0000X
NC218478363L00000X
NC2014029878363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5004974OtherETN P97980