Basic Information
Provider Information | |||||||||
NPI: | 1568659969 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRIFFIN | ||||||||
FirstName: | RAENELLE | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PARKER | ||||||||
OtherFirstName: | RAENELLE | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 22968 TUCKAHOE SPRINGS DR | ||||||||
Address2: |   | ||||||||
City: | DENTON | ||||||||
State: | MD | ||||||||
PostalCode: | 216291615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572849982 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 316 RAILROAD AVE | ||||||||
Address2: |   | ||||||||
City: | GOLDSBORO | ||||||||
State: | MD | ||||||||
PostalCode: | 216361126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106342380 | ||||||||
FaxNumber: | 4104827488 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/28/2007 | ||||||||
LastUpdateDate: | 03/24/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C0003659 | MD | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.