Healthcare Provider Details

I. General information

NPI: 1700271822
Provider Name (Legal Business Name): JILL TANYA HIGH AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 05/03/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 FALLS OF NEUSE RD
RALEIGH NC
27614-7838
US

IV. Provider business mailing address

PO BOX 603949
CHARLOTTE NC
28260-3949
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-8000
  • Fax:
Mailing address:
  • Phone: 919-350-0351
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6308
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5010616
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number5010616
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: