Individual
KIMBERLEY LIS BARRACCO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
12 KANAWHA TER, SAINT ALBANS, WV 25177-2750
(304) 757-6999
Mailing address
PO BOX 2168, SPARTANBURG, SC 29304-2168
(864) 560-4304
(864) 560-4413
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
2064
WV
208000000X
Pediatrics Physician
39076
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001879423
BLUE CROSS BLUE SHEILD
—
05
—
3810005951
—
WV
05
—
390767
—
SC
01
—
7070869
AETNA
—
01
—
SCC510H895
MEDICARE PIN
SC
Enumeration date
09/20/2006
Last updated
09/18/2023
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