Healthcare Provider Details

I. General information

NPI: 1205914512
Provider Name (Legal Business Name): CAROL WOMBLE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 LAKE BRANDT RD
GREENSBORO NC
27455-8414
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-643-5800
  • Fax: 336-643-7474
Mailing address:
  • Phone: 336-643-5800
  • Fax: 336-643-7474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201015
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number000201015
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: