Provider Demographics
NPI:1144893470
Name:SMALLS, BERNADETTE
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:SMALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8601 SIX FORK ROAD, SUITE 400
Mailing Address - Street 2:
Mailing Address - City:RALEIGH N.C
Mailing Address - State:NC
Mailing Address - Zip Code:27597
Mailing Address - Country:US
Mailing Address - Phone:804-218-0745
Mailing Address - Fax:919-676-5305
Practice Address - Street 1:8601SIX FORK ROAD, SUITE 400
Practice Address - Street 2:
Practice Address - City:RALEIGH N.C
Practice Address - State:NC
Practice Address - Zip Code:27597
Practice Address - Country:US
Practice Address - Phone:804-218-0745
Practice Address - Fax:919-676-5305
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC079668164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse