Healthcare Provider Details

I. General information

NPI: 1275004491
Provider Name (Legal Business Name): REBECCA FUQUAY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 BETHESDA DR
GREENVILLE NC
27834-7218
US

IV. Provider business mailing address

300 BETHESDA DR
GREENVILLE NC
27834-7218
US

V. Phone/Fax

Practice location:
  • Phone: 252-752-7141
  • Fax:
Mailing address:
  • Phone: 252-752-7141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number24445
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5011281
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: