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General NPI Number Information
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NPI Number | 1710810437
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Entity Type | Organization
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Legal Business Name | PROVIDENCE PEDIATRIC FUNCTIONAL MEDICINE, PLLC
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Dates
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Enumeration Date | 06/03/2026
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Last Update Date | 06/06/2026
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Provider Practice Location Address
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Address Line | 610 N FAYETTEVILLE ST STE 102
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City | ASHEBORO
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State | NC
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Zip | 27203-4671
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Country | US
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Telephone | 336-233-7882
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Fax |
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Provider Business Mailing Address
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Address Line | 610 N FAYETTEVILLE ST STE 102
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City | ASHEBORO
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State | NC
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Zip | 27203-4671
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Country | US
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Telephone | 336-233-7882
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Fax |
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Authorized Official
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Title or Position | OWNER/AUTHORIZED OFFICIAN
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Name | NICOLE ANDERSON
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Credential | CPNP-PC
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Telephone | 336-233-7882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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