Healthcare Provider Details

I. General information

NPI: 1528090388
Provider Name (Legal Business Name): PROVIDENCE FAMILY PRACTICE ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1043 MARGUERITE DRIVE
LOWELL NC
28098
US

IV. Provider business mailing address

1043 MARGUERITE DRIVE
LOWELL NC
28098
US

V. Phone/Fax

Practice location:
  • Phone: 704-478-6169
  • Fax: 704-478-6169
Mailing address:
  • Phone: 704-478-6169
  • Fax: 704-478-6169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9501625
License Number StateNC

VIII. Authorized Official

Name: MRS. TILDA ABERNATHY JONES
Title or Position: PRACTICE MANAGER
Credential:
Phone: 704-478-6169