Healthcare Provider Details

I. General information

NPI: 1720184005
Provider Name (Legal Business Name): MERRIE BETH GOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 N BRIGHTLEAF BLVD
SMITHFIELD NC
27577-4407
US

IV. Provider business mailing address

7208 RUSTED OAK RD
WAKE FOREST NC
27587-7170
US

V. Phone/Fax

Practice location:
  • Phone: 919-938-7188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number108648
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: