Healthcare Provider Details

I. General information

NPI: 1760417570
Provider Name (Legal Business Name): WAYNESBORO FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 WAYNE MEMORIAL DR
GOLDSBORO NC
27534-2240
US

IV. Provider business mailing address

1706 WAYNE MEMORIAL DR
GOLDSBORO NC
27534-2240
US

V. Phone/Fax

Practice location:
  • Phone: 919-734-6676
  • Fax: 919-734-9050
Mailing address:
  • Phone: 919-734-6676
  • Fax: 919-734-9050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number34D2077478
License Number StateNC

VIII. Authorized Official

Name: NITA VANNOSKE
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 919-734-6676