Healthcare Provider Details

I. General information

NPI: 1912391038
Provider Name (Legal Business Name): KATIE DURHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 BRENNER AVE
SALISBURY NC
28144-2515
US

IV. Provider business mailing address

1601 BRENNER AVE
SALISBURY NC
28144-2515
US

V. Phone/Fax

Practice location:
  • Phone: 704-638-9000
  • Fax:
Mailing address:
  • Phone: 704-638-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5007551
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number5007551
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: