Basic Information
| Provider Information | |||||||||
| NPI: | 1972072114 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAROLLO | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | MARION | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 179 N HARBOR WATCH DR | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286772483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163165392 | ||||||||
| FaxNumber: | 5163165392 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 BLYTHE BLVD | ||||||||
| Address2: | CMC ANNEX, 1ST FLOOR | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043550270 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2018 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | RN282977 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 23520 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 5012470 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | NP64661 | 05 | SC | MEDICAID |