Healthcare Provider Details

I. General information

NPI: 1437920030
Provider Name (Legal Business Name): THE EARLENE CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 06/14/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 SUN RD
ABERDEEN NC
28315-2130
US

IV. Provider business mailing address

775 SUN RD
ABERDEEN NC
28315-2130
US

V. Phone/Fax

Practice location:
  • Phone: 910-517-8080
  • Fax: 888-275-7024
Mailing address:
  • Phone: 910-517-8080
  • Fax: 888-275-7024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MS. ELIZABETH G BAILEY
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 910-517-8080