Healthcare Provider Details

I. General information

NPI: 1396135364
Provider Name (Legal Business Name): NASH STREET HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3725 NASH ST NW
WILSON NC
27896-1127
US

IV. Provider business mailing address

PO BOX 8326
WILSON NC
27893-1326
US

V. Phone/Fax

Practice location:
  • Phone: 252-234-1720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number5004990
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5921229
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: SHARON J MITCHELL
Title or Position: OWNER
Credential: FNP
Phone: 252-234-1720