Healthcare Provider Details

I. General information

NPI: 1023408960
Provider Name (Legal Business Name): MRS. HELEN D FLUDD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2015
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 HENDERSON DR
JACKSONVILLE NC
28540-5601
US

IV. Provider business mailing address

PO BOX 752
JACKSONVILLE NC
28541-0752
US

V. Phone/Fax

Practice location:
  • Phone: 910-939-4663
  • Fax: 910-939-5079
Mailing address:
  • Phone: 910-939-4663
  • Fax: 910-939-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: