Healthcare Provider Details

I. General information

NPI: 1477183853
Provider Name (Legal Business Name): TERRESA M BAZELOW FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 W ARLINGTON BLVD
GREENVILLE NC
27834-5704
US

IV. Provider business mailing address

2313 FLAGSTAFF CT
GREENVILLE NC
27858-9630
US

V. Phone/Fax

Practice location:
  • Phone: 252-413-6202
  • Fax:
Mailing address:
  • Phone: 703-568-7076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5012743
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: