1215009758 NPI number — CATHY GRIFFITTS CLARK FNP

Table of content: CATHY GRIFFITTS CLARK FNP (NPI 1215009758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215009758 NPI number — CATHY GRIFFITTS CLARK FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
CATHY
Provider Middle Name:
GRIFFITTS
Provider Name Prefix Text:
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:
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:
1215009758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 369
Provider Second Line Business Mailing Address:
200 HOSPITAL AVENUE, SUITE 3
Provider Business Mailing Address City Name:
JEFFERSON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28640-0369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-846-7433
Provider Business Mailing Address Fax Number:
336-846-7878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 HOSPITAL AVE STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28640-9244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-846-7433
Provider Business Practice Location Address Fax Number:
336-846-7878
Provider Enumeration Date:
11/13/2006

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: 363LF0000X , with the licence number:  0050-02179 , 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: 162V5 . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7003870 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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