Healthcare Provider Details

I. General information

NPI: 1619961620
Provider Name (Legal Business Name): BONITA C AYCOCK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DODD ST
SPRING HOPE NC
27882-9348
US

IV. Provider business mailing address

PO BOX 7200
ROCKY MOUNT NC
27804-0200
US

V. Phone/Fax

Practice location:
  • Phone: 252-478-5412
  • Fax: 252-937-3100
Mailing address:
  • Phone: 252-937-0200
  • Fax: 252-451-0056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200892
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500005810
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerRAILROAD MEDICARE
# 2
Identifier1619961620
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerNPI
# 3
Identifier58594
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerMEDICAL LICENSE
# 4
Identifier7000422
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 5
Identifier363L00000X
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerTAXONOMY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: