Healthcare Provider Details

I. General information

NPI: 1902739048
Provider Name (Legal Business Name): JUSTINE HANNAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 08/16/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 HIGHLAND AVE
WINSTON SALEM NC
27101-4206
US

IV. Provider business mailing address

376 MEADOWBROOK CT
GRANITE FALLS NC
28630-8124
US

V. Phone/Fax

Practice location:
  • Phone: 828-292-2803
  • Fax:
Mailing address:
  • Phone: 828-292-2803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5025200
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: