Basic Information
Provider Information | |||||||||
NPI: | 1033358213 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ACT MEDICAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 311 JUDGES RD STE 4E | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | NC | ||||||||
PostalCode: | 284053655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9107916767 | ||||||||
FaxNumber: | 9107918490 | ||||||||
Practice Location | |||||||||
Address1: | 311 JUDGES RD STE 4E | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | NC | ||||||||
PostalCode: | 284053655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9107916767 | ||||||||
FaxNumber: | 9107918490 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2009 | ||||||||
LastUpdateDate: | 02/12/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YEBOAH | ||||||||
AuthorizedOfficialFirstName: | MAVIS | ||||||||
AuthorizedOfficialMiddleName: | OSEI | ||||||||
AuthorizedOfficialTitleorPosition: | FAMILY NURSE PRACTITIONER | ||||||||
AuthorizedOfficialTelephone: | 3363580033 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | FNP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 5004181 | NC | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.