=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346996915
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAILA GOWANI VALLIANI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2022
-----------------------------------------------------
Last Update Date | 02/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 529 BECKER DR
-----------------------------------------------------
City | ROANOKE RAPIDS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27870-3303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-537-6465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 DEERFIELD PL
-----------------------------------------------------
City | ROANOKE RAPIDS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27870-3305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-673-6243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 5015684
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------