Healthcare Provider Details

I. General information

NPI: 1265032536
Provider Name (Legal Business Name): HEIDI ELLEN JUMBERCOTTA NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 OWEN DR
FAYETTEVILLE NC
28304-3424
US

IV. Provider business mailing address

2402 MARKET ST
WILMINGTON NC
28403-1136
US

V. Phone/Fax

Practice location:
  • Phone: 910-615-4000
  • Fax:
Mailing address:
  • Phone: 910-367-2766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number5013687
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number5013687
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: