Provider Demographics
NPI:1699788372
Name:WILLIAMSON, KIMBERLY S (CPO, CFM)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:S
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:CPO, CFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 MEDICAL DRIVE
Mailing Address - Street 2:PO BOX 1471
Mailing Address - City:ELIZ CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909
Mailing Address - Country:US
Mailing Address - Phone:252-338-3002
Mailing Address - Fax:252-338-2902
Practice Address - Street 1:106 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:ELIZ CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-338-3002
Practice Address - Fax:252-338-2902
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCPO03814222Z00000X, 224P00000X
NC332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0482POtherBCBS
VA9190511Medicaid
VA384410OtherBCBS
NC7701327Medicaid
NC0482POtherBCBS