Basic Information
| Provider Information | |||||||||
| NPI: | 1902394067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESRONVIL | ||||||||
| FirstName: | THEODORA | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2723 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278022723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522123486 | ||||||||
| FaxNumber: | 2522123497 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 N GRACE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278045345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522109856 | ||||||||
| FaxNumber: | 2528225065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2018 | ||||||||
| LastUpdateDate: | 06/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 303827 | NC | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 5010560 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.