1467539965 NPI number — DEBORAH H NIFONG

Table of content: DEBORAH H NIFONG (NPI 1467539965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467539965 NPI number — DEBORAH H NIFONG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIFONG
Provider First Name:
DEBORAH
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1467539965
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2085 FRONTIS PLAZA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27103-5614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-277-7226
Provider Business Mailing Address Fax Number:
336-277-9795

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 S HAWTHORNE RD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-3921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-718-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2006

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: 363L00000X , with the licence number:  200176 , 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: 7003880 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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