Healthcare Provider Details

I. General information

NPI: 1386265858
Provider Name (Legal Business Name): EMILY FITZGERALD REGAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL STE 200
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

571 S ALLEN RD
FLAT ROCK NC
28731-9447
US

V. Phone/Fax

Practice location:
  • Phone: 984-215-5588
  • Fax: 919-570-6383
Mailing address:
  • Phone: 828-692-6178
  • Fax: 828-692-2365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5013106
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5013106
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: