Healthcare Provider Details

I. General information

NPI: 1790944049
Provider Name (Legal Business Name): MRS. COLLETTA LAVINA REDMON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 S SUTHERLAND AVE
MONROE NC
28112-5060
US

IV. Provider business mailing address

193 REDMON RD
HARMONY NC
28634-9249
US

V. Phone/Fax

Practice location:
  • Phone: 704-291-9267
  • Fax:
Mailing address:
  • Phone: 980-378-3716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number630555
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: