Provider Demographics
NPI:1548675648
Name:SOUTHERLAND, VERONICA (FNP)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8129 MADRIGAL CT
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-8099
Mailing Address - Country:US
Mailing Address - Phone:704-408-5096
Mailing Address - Fax:
Practice Address - Street 1:8129 MADRIGAL CT
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-8099
Practice Address - Country:US
Practice Address - Phone:704-408-5096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006949363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily