Healthcare Provider Details

I. General information

NPI: 1699879239
Provider Name (Legal Business Name): BERTHA LEE HENDRIX OGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 FOUNTAINHEAD LN
FAYETTEVILLE NC
28301-5417
US

IV. Provider business mailing address

1112 PLEASANT OAK DR
FAYETTEVILLE NC
28314-5930
US

V. Phone/Fax

Practice location:
  • Phone: 910-433-3647
  • Fax: 910-433-3701
Mailing address:
  • Phone: 910-868-6171
  • Fax: 910-433-3701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number80575
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: