=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386950418
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN MICHAEL REILLY RNC,NNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2010
-----------------------------------------------------
Last Update Date | 03/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4420 LAKE BOONE TRL
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27607-7505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-784-3100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4420 LAKE BOONE TRL
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27607-7505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-784-3100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LN0005X
-----------------------------------------------------
Taxonomy Name | Critical Care Neonatal Nurse Practitioner
-----------------------------------------------------
License Number | COA07506NP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LN0005X
-----------------------------------------------------
Taxonomy Name | Critical Care Neonatal Nurse Practitioner
-----------------------------------------------------
License Number | 5009794
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------