Basic Information
| Provider Information | |||||||||
| NPI: | 1720646227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STONEBACK | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ANN | ||||||||
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| OtherLastName: | ROGERS | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1008 PINE ACRES CT | ||||||||
| Address2: | |||||||||
| City: | KNIGHTDALE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275458876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196107975 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 107 SUNNYBROOK RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9849744800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2019 | ||||||||
| LastUpdateDate: | 02/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 5011996 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.