Basic Information
| Provider Information | |||||||||
| NPI: | 1164161519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAND | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | CLARK | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2819 WINTON PL | ||||||||
| Address2: | |||||||||
| City: | HILLSBOROUGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272787569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194758893 | ||||||||
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| Practice Location | |||||||||
| Address1: | 503 BOWMAN GRAY DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278347286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528164001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2022 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5016292 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.