Basic Information
| Provider Information | |||||||||
| NPI: | 1578132908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARGO | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | AGNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2302 FORTUNE LN | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274085412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362541233 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1309 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365445400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2021 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 5014565 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | 5014565 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | AG06210063 | 01 | AMERICAN ACADEMY OF NURSE PRACTITIONERS | OTHER | 5014565 | 01 | NC | NORTH CAROLINA BOARD OF NURSING | OTHER |