1417165176 NPI number — MS. SHELLY HOWARD WEGMAN RD, LDN

Table of content: MS. SHELLY HOWARD WEGMAN RD, LDN (NPI 1417165176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417165176 NPI number — MS. SHELLY HOWARD WEGMAN RD, LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEGMAN
Provider First Name:
SHELLY
Provider Middle Name:
HOWARD
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LDN
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:
1417165176
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
211 FRIDAY CENTER DRIVE,
Provider Second Line Business Mailing Address:
SUITE 2091, ROOM 2094 HEDRICK BUILDING
Provider Business Mailing Address City Name:
CHAPEL HILL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27517-9499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
984-974-1191
Provider Business Mailing Address Fax Number:
984-974-1311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 TIMBER DRIVE EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARNER
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27529-6925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-661-6100
Provider Business Practice Location Address Fax Number:
919-661-6101
Provider Enumeration Date:
05/18/2007

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: 133NN1002X , with the licence number:  L002059 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: L002059 , 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: Q50643E853 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: Q50643A . This is a "MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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