Healthcare Provider Details

I. General information

NPI: 1164042982
Provider Name (Legal Business Name): PHYLLIS COULTER EVERETT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3803 PEACHTREE AVE
WILMINGTON NC
28403-6727
US

IV. Provider business mailing address

21430 TIMBERLAKE RD
LYNCHBURG VA
24502-7248
US

V. Phone/Fax

Practice location:
  • Phone: 910-799-6262
  • Fax: 910-799-6261
Mailing address:
  • Phone: 434-944-0194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRIANA MCWILLIAMS
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 800-828-2012