Healthcare Provider Details

I. General information

NPI: 1457195422
Provider Name (Legal Business Name): MARIA SERGEYEVNA WITHROW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 N CHURCH ST
GREENSBORO NC
27401-1007
US

IV. Provider business mailing address

1007 WALKER AVE
GREENSBORO NC
27403
US

V. Phone/Fax

Practice location:
  • Phone: 336-988-7799
  • Fax:
Mailing address:
  • Phone: 336-344-5105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5022814
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number271289
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: