1174864656 NPI number — CATHY GAYLE MANN FNP-C

Table of content: CATHY GAYLE MANN FNP-C (NPI 1174864656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174864656 NPI number — CATHY GAYLE MANN FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANN
Provider First Name:
CATHY
Provider Middle Name:
GAYLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
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:
1174864656
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 986513
Provider Second Line Business Mailing Address:
DEPT 100
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02298-6513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-219-8326
Provider Business Mailing Address Fax Number:
910-939-4269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
338 HOWARD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28570-7928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-223-5054
Provider Business Practice Location Address Fax Number:
252-223-4038
Provider Enumeration Date:
03/08/2013

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:  20244 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 5006106 , 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: NP4065 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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