Basic Information
| Provider Information | |||||||||
| NPI: | 1295321255 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SALLOUM | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38 ROYAL COUNTY DOWN | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096490851 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 LAUCHWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAURINBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283525599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102917000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2020 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-10881 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.