Healthcare Provider Details

I. General information

NPI: 1962481259
Provider Name (Legal Business Name): JENNIFER M TRELLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3432 GREENVILLE LOOP RD
WAKE FOREST NC
27587-9380
US

IV. Provider business mailing address

3432 GREENVILLE LOOP RD
WAKE FOREST NC
27587-9380
US

V. Phone/Fax

Practice location:
  • Phone: 919-217-4059
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2006-0053
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: