Healthcare Provider Details

I. General information

NPI: 1225325228
Provider Name (Legal Business Name): SALLY C FREAS RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 PHYSICIANS DR
WILMINGTON NC
28401-7356
US

IV. Provider business mailing address

2511 DELANEY AVE ATTN: CREDENTIALING
WILMINGTON NC
28403-6003
US

V. Phone/Fax

Practice location:
  • Phone: 910-341-3300
  • Fax: 910-251-8824
Mailing address:
  • Phone: 910-772-9202
  • Fax: 866-345-8963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number85144
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number0882-5146
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: