Healthcare Provider Details

I. General information

NPI: 1700386711
Provider Name (Legal Business Name): JENELLE SILLS FLEMING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2018
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 HAY ST
FAYETTEVILLE NC
28305-5312
US

IV. Provider business mailing address

806 HAY ST
FAYETTEVILLE NC
28305-5312
US

V. Phone/Fax

Practice location:
  • Phone: 910-860-7008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006949
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110006078
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-09851
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: