Healthcare Provider Details

I. General information

NPI: 1669547766
Provider Name (Legal Business Name): WAKE NEUROLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 06/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 SE CARY PKWY SUITE 206
CARY NC
27518-7420
US

IV. Provider business mailing address

1110 SE CARY PKWY SUITE 206
CARY NC
27518-7420
US

V. Phone/Fax

Practice location:
  • Phone: 919-463-1101
  • Fax: 919-463-1110
Mailing address:
  • Phone: 919-463-1101
  • Fax: 919-463-1110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number200400217
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number2423
License Number StateNC

VIII. Authorized Official

Name: MRS. KRISTY DRISKELL
Title or Position: OFFICE ADMINISTRATOR/NURSE
Credential:
Phone: 919-463-1101