Basic Information
| Provider Information | |||||||||
| NPI: | 1417020751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MISHRA | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | MARGARET | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | WHNP-C, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEAVER | ||||||||
| OtherFirstName: | ELLEN | ||||||||
| OtherMiddleName: | MARGARET | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | WHNP, FNP-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 60 COMMERCE PLAZA CIR | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283727386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105212900 | ||||||||
| FaxNumber: | 9107759165 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 E MONROE ST | ||||||||
| Address2: | |||||||||
| City: | DILLON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295362557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437744337 | ||||||||
| FaxNumber: | 8437744373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3943 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP1474 | 05 | SC | MEDICAID | P00939456 | 01 | SC | RAILROAD MEDIARE PTAN | OTHER |