Healthcare Provider Details

I. General information

NPI: 1750995676
Provider Name (Legal Business Name): BEVERLY M MOTT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 RIVER VINE PKWY
WALLACE NC
28466-2377
US

IV. Provider business mailing address

125 RIVER VINE PKWY
WALLACE NC
28466-2377
US

V. Phone/Fax

Practice location:
  • Phone: 910-285-2134
  • Fax: 910-285-4610
Mailing address:
  • Phone: 910-285-2134
  • Fax: 910-285-4610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5013422
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: