Healthcare Provider Details

I. General information

NPI: 1124947189
Provider Name (Legal Business Name): AMY LISSETTE VANCE RICO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8396 SIX FORKS RD STE 102
RALEIGH NC
27615-3058
US

IV. Provider business mailing address

2217 CANTERBURY DR
BURLINGTON NC
27215-4524
US

V. Phone/Fax

Practice location:
  • Phone: 919-576-0390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP022667
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: