Healthcare Provider Details

I. General information

NPI: 1104780576
Provider Name (Legal Business Name): SAVANNAH RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 E HAGGARD AVE
ELON NC
27244-8417
US

IV. Provider business mailing address

762 E HAGGARD AVE
ELON NC
27244-8417
US

V. Phone/Fax

Practice location:
  • Phone: 336-278-6860
  • Fax:
Mailing address:
  • Phone: 336-278-6860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: