Provider Demographics
NPI:1760044762
Name:IMMORDINO, STEPHEN (MSN, FNP, NP-C, CDE)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:IMMORDINO
Suffix:
Gender:M
Credentials:MSN, FNP, NP-C, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 WENDY LN
Mailing Address - Street 2:
Mailing Address - City:EFLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27243-9675
Mailing Address - Country:US
Mailing Address - Phone:516-319-3966
Mailing Address - Fax:
Practice Address - Street 1:3724 WIRELESS DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-3312
Practice Address - Country:US
Practice Address - Phone:336-540-9991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011944207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine