Healthcare Provider Details

I. General information

NPI: 1649079047
Provider Name (Legal Business Name): JOHNKENVER DARYELL MAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 SUMMERHAVEN DR APT B
GREENVILLE NC
27858-6183
US

IV. Provider business mailing address

2000 SUMMERHAVEN DR APT B
GREENVILLE NC
27858-6183
US

V. Phone/Fax

Practice location:
  • Phone: 240-615-4931
  • Fax: 240-615-4931
Mailing address:
  • Phone: 240-615-4931
  • Fax: 240-615-4931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number000009738563
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: