Healthcare Provider Details

I. General information

NPI: 1497458327
Provider Name (Legal Business Name): TIMIKA WALKER GORHAM LICENSE PRACTICAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E ARLINGTON BLVD STE C
GREENVILLE NC
27858-5019
US

IV. Provider business mailing address

150 E ARLINGTON BLVD STE C
GREENVILLE NC
27858-5019
US

V. Phone/Fax

Practice location:
  • Phone: 252-353-2555
  • Fax: 252-565-0137
Mailing address:
  • Phone: 252-353-2555
  • Fax: 252-565-0137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number92226
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: