Healthcare Provider Details

I. General information

NPI: 1003889080
Provider Name (Legal Business Name): JOHN HUDSON FILLMORE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 WHITEVILLE RD NW
SHALLOTTE NC
28470-6503
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-4441
  • Fax:
Mailing address:
  • Phone: 910-754-4441
  • Fax: 910-754-5307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200786
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: