=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770836587
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISS GLORIA ANN COMBS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2012
-----------------------------------------------------
Last Update Date | 10/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1699 WEEKSVILLE RD 106 D
-----------------------------------------------------
City | ELIZABETH CTY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27909-7939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-505-1453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1699 WEEKSVILLE RD 106 D
-----------------------------------------------------
City | ELIZABETH CTY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27909-7939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-505-1453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374700000X
-----------------------------------------------------
Taxonomy Name | Technician
-----------------------------------------------------
License Number | 20-0691R09
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | 22727
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------