Basic Information
| Provider Information | |||||||||
| NPI: | 1730511924 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONVILLE | ||||||||
| FirstName: | NECOLE | ||||||||
| MiddleName: | FELICE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 538622 | ||||||||
| Address2: | LIFESOURCE OF NORTH CAROLINA | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303538622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107429243 | ||||||||
| FaxNumber: | 8887461787 | ||||||||
| Practice Location | |||||||||
| Address1: | 1213 CULBRETH DR | ||||||||
| Address2: | LIFESOURCE OF NORTH CAROLINA/LANDFALL EXECUTIVE SUITES | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284053639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107429243 | ||||||||
| FaxNumber: | 8887461787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2013 | ||||||||
| LastUpdateDate: | 03/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5006247 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 5006247 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | 5006247 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.