Healthcare Provider Details

I. General information

NPI: 1700486685
Provider Name (Legal Business Name): CAMERON BLAKE LITTLE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

1949 BLACKWOLF RUN LN
RALEIGH NC
27604-5405
US

V. Phone/Fax

Practice location:
  • Phone: 919-787-5380
  • Fax:
Mailing address:
  • Phone: 252-299-2658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number5014135
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5014135
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5014135
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: