Provider Demographics
NPI:1194325746
Name:KING, KORETTA A
Entity type:Individual
Prefix:
First Name:KORETTA
Middle Name:A
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KORETTA
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:152 QUEENSBERRY CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-4899
Mailing Address - Country:US
Mailing Address - Phone:336-254-3867
Mailing Address - Fax:
Practice Address - Street 1:152 QUEENSBERRY CT
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-4899
Practice Address - Country:US
Practice Address - Phone:336-254-3867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC90647164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse