=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548950439
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAIGE JERNIGAN PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2023
-----------------------------------------------------
Last Update Date | 05/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 VAN HAVEN DR
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28625-4342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-883-9700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 S AVONDALE RD
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27292-5805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-465-3315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A8079
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------