1083695118 NPI number — MRS. ADRIENNE YOLANDA SMALL FNP

Table of content: MRS. ADRIENNE YOLANDA SMALL FNP (NPI 1083695118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083695118 NPI number — MRS. ADRIENNE YOLANDA SMALL FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMALL
Provider First Name:
ADRIENNE
Provider Middle Name:
YOLANDA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FULLARD
Provider Other First Name:
ADRIENNE
Provider Other Middle Name:
YOLANDA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083695118
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 BLUEBIRD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27713-8139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-403-8816
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4104 SURLES CT
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27703-8056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-941-1911
Provider Business Practice Location Address Fax Number:
919-941-1901
Provider Enumeration Date:
11/07/2005

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: 363LF0000X , with the licence number:  200950 , 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)





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