MEDICARE: ELIZABETH A DEATON PNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0000X	Adolescent Medicine (Family Medicine) Physician	300139	NC
2	363LP0200X	Pediatric Nurse Practitioner	75702	NC
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	300139	NC

General Provider Information

NPI Number	:	1447254438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH A DEATON PNP

Provider Business Mailing Address
First Line	:	615 SHIPYARD BLVD
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28412-6431
Country	:	US
Telephone Number	:	910-343-0145
Fax Number	:	910-341-5779

Provider Business Practice Location Address
First Line	:	615 SHIPYARD BLVD
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28412-6431
Country	:	US
Telephone Number	:	910-343-0145
Fax Number	:	910-341-5779

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	09/15/2015

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