1336246289 NPI number — FREDENA LUCAS JAGGERS CRNA

Table of content: MRS. TISHA KIM ELLIS APRN, PMHNP-BC (NPI 1164058723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336246289 NPI number — FREDENA LUCAS JAGGERS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAGGERS
Provider First Name:
FREDENA
Provider Middle Name:
LUCAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336246289
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
128 PEACHTREE LN STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADVANCE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27006-6783
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-624-1648
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2170 MIDLAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHERN PINES
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28387-2927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-295-1221
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  004545 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 430056454 . This is a "HRH RR CRNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8051710 . This is a "MEDICAID CRNA PRO." identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 170062 . This is a "LICENSE NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8000180 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8000315 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 430079566 . This is a "SCH RR CRNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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