Basic Information
Provider Information | |||||||||
NPI: | 1528021177 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DANIEL | ||||||||
FirstName: | JANICE | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEBELL | ||||||||
OtherFirstName: | JANICE | ||||||||
OtherMiddleName: | B | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 211 SHELTON RD | ||||||||
Address2: |   | ||||||||
City: | STOKESDALE | ||||||||
State: | NC | ||||||||
PostalCode: | 273578204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3364089484 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1510 NC HIGHWAY 68 N | ||||||||
Address2: |   | ||||||||
City: | OAK RIDGE | ||||||||
State: | NC | ||||||||
PostalCode: | 273109733 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3366440111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2006 | ||||||||
LastUpdateDate: | 04/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 201192 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 7004186 | 05 | NC |   | MEDICAID |