Healthcare Provider Details

I. General information

NPI: 1649314840
Provider Name (Legal Business Name): MRS. MARY JONES SOMERVILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 W FRANKLIN ST
WARRENTON NC
27589-1937
US

IV. Provider business mailing address

686 AXTELL RIDGEWAY RD
NORLINA NC
27563-9250
US

V. Phone/Fax

Practice location:
  • Phone: 252-257-4568
  • Fax: 252-257-2388
Mailing address:
  • Phone: 252-456-4239
  • Fax: 252-456-3718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number715493
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: