=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548765167
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEMISSIE H SOLOMON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2018
-----------------------------------------------------
Last Update Date | 06/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 910 W HARRISON ST
-----------------------------------------------------
City | REIDSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27320-3324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-342-9564
-----------------------------------------------------
Fax | 336-349-9723
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 910 W HARRISON ST
-----------------------------------------------------
City | REIDSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27320-3324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-342-9564
-----------------------------------------------------
Fax | 336-349-9723
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Registered Nurse
-----------------------------------------------------
License Number | APRN002862
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | APRN002862
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 5013570
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------