Basic Information
| Provider Information | |||||||||
| NPI: | 1720104409 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROLINA HEALTHCARE ASSOCIATES, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NURSE PRACTITIONERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2218 S 17TH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103437000 | ||||||||
| FaxNumber: | 9107729452 | ||||||||
| Practice Location | |||||||||
| Address1: | 2131 S 17TH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103437000 | ||||||||
| FaxNumber: | 9107729452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURTON | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9103437000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 7000489 | 05 | NC | MEDICAID |