1568751121 NPI number — MS. DEREZMA LASHON LITTLE QP, MA

Table of content: MS. DEREZMA LASHON LITTLE QP, MA (NPI 1568751121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568751121 NPI number — MS. DEREZMA LASHON LITTLE QP, MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LITTLE
Provider First Name:
DEREZMA
Provider Middle Name:
LASHON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
QP, 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:
1568751121
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3901 BATTLEGROUND AVE. APT. 30
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-931-1800
Provider Business Mailing Address Fax Number:
336-931-1801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7900 TRIAD CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27409-9073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-931-1800
Provider Business Practice Location Address Fax Number:
336-931-1802
Provider Enumeration Date:
04/05/2011

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 101YM0800X , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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