1912958604 NPI number — CHRISTINA REBECCA DEMARY MA

Table of content: KENDRA LEIGH WAMSLEY (NPI 1225807373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912958604 NPI number — CHRISTINA REBECCA DEMARY MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMARY
Provider First Name:
CHRISTINA
Provider Middle Name:
REBECCA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA
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:
1912958604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
323 NORTH MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-639-1616
Provider Business Mailing Address Fax Number:
704-639-1699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 W COUNCIL ST
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28144-4357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-639-1616
Provider Business Practice Location Address Fax Number:
704-639-1699
Provider Enumeration Date:
05/15/2006

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: 101YA0400X , with the licence number:  MHL-080-135 , 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: 133J8 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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