{
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"EIN": null,
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"FirstLineMailingAddress": "PO BOX 1273",
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"MailingAddressCityName": "JAMESTOWN",
"MailingAddressStateName": "NC",
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"MailingAddressCountryCode": "US",
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"MailingAddressFaxNumber": "336-203-2213",
"FirstLinePracticeLocationAddress": "105 BRANTMERE CT",
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"PracticeLocationAddressCityName": "JAMESTOWN",
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"PracticeLocationAddressTelephoneNumber": "336-554-3092",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "11/18/2020",
"LastUpdateDate": "11/19/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
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"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
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"LicenseNumber": "N95779",
"LicenseNumberStateCode": "NC",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}