Provider Demographics
NPI:1962993907
Name:BRAILSFORD, KIMBERLY HUMPHREY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:HUMPHREY
Last Name:BRAILSFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 HORSESHOE LN
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425-8229
Mailing Address - Country:US
Mailing Address - Phone:910-352-9054
Mailing Address - Fax:
Practice Address - Street 1:208 MERCER ROAD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337
Practice Address - Country:US
Practice Address - Phone:910-862-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390720224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09170607461OtherAHA BLS
390720OtherNBCOT
NC11366OtherNCBOT